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Long B, Easter J, Koyfman A. High risk and low incidence diseases: Pediatric digestive volvulus. Am J Emerg Med 2024; 82:153-160. [PMID: 38908340 DOI: 10.1016/j.ajem.2024.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 06/10/2024] [Accepted: 06/12/2024] [Indexed: 06/24/2024] Open
Abstract
INTRODUCTION Pediatric digestive volvulus is a serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of pediatric digestive volvulus, including the presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION Pediatric digestive volvulus is a deadly condition most commonly associated with malrotation. It occurs when the stomach or small intestine twists on itself, resulting in ischemia and potentially strangulation with necrosis and perforation. Presentation differs based on the gastrointestinal (GI) segment affected, degree of twisting, and acuity of the volvulus. Gastric volvulus most commonly presents with retching with or without nonbilious emesis and epigastric distension with pain, while midgut volvulus typically presents with bilious emesis in infants. Patients with GI necrosis and perforation may present with hemodynamic compromise and peritonitis. If suspected, emergent consultation with the pediatric surgery specialist is necessary, and if this is not available, transfer to a center with a pediatric surgeon is recommended. Imaging includes plain radiography, ultrasound, or upper GI series, while treatment includes resuscitation, administration of antibiotics, and emergent surgical decompression and detorsion of the involved segments. CONCLUSION An understanding of pediatric digestive volvulus and its many potential mimics can assist emergency clinicians in diagnosing and managing this deadly disease.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Joshua Easter
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
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Zhou W, Dan J, Zhu M, Liao Q, Liu K, Wang Y. Two exploratory laparotomies within six days: A case of midgut volvulus in an adult with congenital malrotation. Int J Surg Case Rep 2024; 120:109836. [PMID: 38824740 PMCID: PMC11169454 DOI: 10.1016/j.ijscr.2024.109836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 05/24/2024] [Accepted: 05/28/2024] [Indexed: 06/04/2024] Open
Abstract
INTRODUCTION Midgut volvulus in adults based on congenital malrotation, which required emergency surgery, may occur under the stimulation of adverse factors and is rare and easy to be misdiagnosed. PRESENTATION OF CASE A young male was taken to the emergency room of a local hospital after six hours abdominal pain. Computed tomography (CT) shows intestinal volvulus and exploratory laparotomy was performed. Postoperative CT revealed remission of small intestinal torsion and congenital malrotation of the midgut. The patient vomited frequently within 48 h after the surgery, and was transferred to our hospital for conservative treatment. After 4 days of conservative treatment, the vomiting symptoms were relieved at first, but worsened again after a liquid diet. CT showed complete duodenal obstruction and exploratory laparotomy was performed again. Congenital malrotation was found, which resulted in midgut volvulus and duodenal obstruction due to anomalous fixation of the mesentery. The bowel was placed in normal anatomical position, and the mesentery was sutured to the posterior abdominal wall. The patient was followed up for 24 months with no complaints. DISCUSSION Due to the rare incidence and atypical pain clinical manifestations, it is difficult for the congenital malrotation in adults to be diagnosed. Midgut volvulus in adults with malrotation is even rarer and requires emergency operation, and may be misdiagnosed. CONCLUSION Midgut volvulus with midgut malrotation is very rare in adults. Exploratory laparotomy must be careful to reduce misdiagnosis and recurrence of volvulus.
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Affiliation(s)
- Wenjie Zhou
- Department of Gastrointestinal Surgery, The People's Hospital of Leshan, Leshan 614000, Sichuan Province, China
| | - Jie Dan
- Department of Gastrointestinal Surgery, The People's Hospital of Leshan, Leshan 614000, Sichuan Province, China
| | - Mingjie Zhu
- Department of Gastrointestinal Surgery, The People's Hospital of Leshan, Leshan 614000, Sichuan Province, China
| | - Qian Liao
- Department of Gastrointestinal Surgery, The People's Hospital of Leshan, Leshan 614000, Sichuan Province, China
| | - Ke Liu
- Department of Gastrointestinal Surgery, The People's Hospital of Leshan, Leshan 614000, Sichuan Province, China
| | - YongHong Wang
- Department of Gastrointestinal Surgery, The People's Hospital of Leshan, Leshan 614000, Sichuan Province, China.
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Kumar S, Nepal P, Kumar D, Tirumani SH, Nagar A, Ojili V. Twists and turns in acute abdomen: imaging spectrum of torsions and volvulus. Clin Imaging 2022; 87:11-27. [DOI: 10.1016/j.clinimag.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/22/2022] [Accepted: 04/11/2022] [Indexed: 11/03/2022]
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Sonographic diagnosis of malrotation: it's complicated - counterpoint. Pediatr Radiol 2022; 52:723-725. [PMID: 34389875 DOI: 10.1007/s00247-021-05163-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 03/05/2021] [Accepted: 07/26/2021] [Indexed: 01/30/2023]
Abstract
Focused abdominal sonography (US) has been suggested as a first-line modality for the diagnosis of malrotation and volvulus in newborns. In this paper, the author reviews the strengths and weaknesses of US in the diagnosis and exclusion of malrotation and volvulus. The author reviews published implementation programs for using US in both conditions and describes the anatomical variations that limit the utility of US depiction of a retromesenteric duodenum in the exclusion of malrotation.
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Can the Third Part of Duodenum Behind SMA Be Detected With Confidence on CT as a Proposed Mechanism for Imaging Suspected Malrotation in Children? A Preliminary Proof of Concept Study. J Comput Assist Tomogr 2022; 46:344-348. [PMID: 35285821 DOI: 10.1097/rct.0000000000001280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM The aims of this study were to determine frequency and reliability of computed tomography (CT) detection of anatomic landmarks for imaging suspected midgut malrotation in infants and children, and to calculate an estimated effective dose of an upper abdominal CT scan in our patient population. MATERIALS AND METHODS Fifty consecutive pediatric patients who underwent a CT scan that included their upper abdomen between August 2016 and February 2018 were included. Four pediatric radiology consultants independently reviewed CT scans for detection of the third part of the duodenum and defined their confidence level of this through identification of continuity with the pyloric antrum, D1, D2, and D4 components of the duodenum, as well as the duodenojejunal flexure.Interobserver variability was assessed using Fleiss κ for agreement. A dose estimate, per scan, was calculated using the scanner dose-length product and published conversion factors by Deak. RESULTS Thirty patients were boys. The average age was 7.5 ± 5.4 years (6 days to 16 years). The D3 segment was definitely identified in 70% of scans, with 68% to 73%, moderate agreement between the readers and a Fleiss κ of 0.47 to 0.52. The DJ flexure was definitely identified in only 30.5% cases, with 35%, poor agreement between readers (Fleiss κ of 0.03). The average estimated dose for a targeted CT scan of the abdomen was 0.9 mSv (0.04-2.4 mSv). CONCLUSIONS The third part of the duodenum, which is integral in excluding malrotation on cross-sectional studies, was "definitely" identified in 70% of CT scans of children in our study, with 68% to 73% agreement between the readers and a Fleiss κ of 0.47 to 0.52.These preliminary proof of concept results demonstrating a combination of a comparable CT dose in relation to upper gastrointestinal contrast studies and an acceptable number of cases delineating the third part of the duodenum with moderate agreement are a first step in suggesting low-dose CT for an imaging diagnosis of malrotation. Malrotation can be excluded in cases where D3 is well demonstrated in the normal position, which negates the need to automatically refer children with bilious emesis to specialist centers for upper gastrointestinal contrast studies.
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Ultrasound for Midgut Malrotation and Midgut Volvulus: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2022; 218:931-939. [PMID: 35107311 DOI: 10.2214/ajr.21.27242] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Midgut volvulus in association with malrotation is a pediatric surgical emergency. Prompt and accurate diagnosis is necessary to avoid bowel ischemia and necrosis, thereby reducing morbidity and mortality. Historically, the upper gastrointestinal (UGI) series has been the preferred imaging modality for the evaluation of both midgut malrotation and volvulus, although use of ultrasound (US) is increasing. In this narrative review, we describe the findings of midgut malrotation and volvulus on US, including practical tips for acquisition and interpretation; discuss the advantages and challenges of both imaging modalities; and propose a path and safeguards for possible transition to the use of US as the first-line modality for diagnosis, based on our experience in imaging children with midgut malrotation and volvulus.
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Alamdaran SA, Mahdavi Rashed M, Arjmand S, Rahimzadeh Oskooei R. Mesenteric Vessel Abnormalities Detected With Sonography: A Possible Gateway to the Early Diagnosis of Various Gastrointestinal Anomalies. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2021. [DOI: 10.1177/8756479320961076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: In pediatric sonography, mesenteric vessel abnormalities can be used as a sign of malrotation or volvulus. This study was aimed at evaluating the diseases associated with mesenteric vessel abnormalities in children, except for rotational anomalies. Methods: From 2017 to 2020, pediatric patients with abdominal complaints were referred for a full abdominal sonogram and were evaluated for mesenteric vascular abnormalities. During this period, 62 children (aged <12 years), with mesenteric vessel abnormalities, were discovered with sonography. They were also examined for associated anomalies and were followed until a final diagnosis was determined. Results: Mesenteric vessel displacement was reported in 37 patients (60%); in 24 cases, the vein was located to the left of superior mesenteric artery (SMA), and in others (13 cases), in the anterior position. Abnormal pathways in mesenteric vessels were reported in 33 patients (53%); 18 cases showing a right side turn and 15 cases showing a left side turn. The whirlpool sign was seen in 16 patients (27%). These three patterns of vessel abnormality were associated with disorders such as diaphragmatic hernia, bowel obstruction, and space occupying lesions (masses). The location of the mesenteric abnormality was in the proximal part of mesenteric vessels in 45 cases (72.5%) and in its distal part in 17 cases (27.5%). Malrotation (eight cases), obstruction, and volvulus were the most common causes of a distal abnormality. Conclusions: Mesenteric vessel abnormalities, noted with sonography, may not be exclusive to the diagnosis of malrotation and midgut volvulus. In this cohort, bowel obstruction, diaphragmatic hernia, and space occupying lesions were the other most common anomalies associated with mesenteric vessel abnormalities. In reviewing one-third of mesenteric vessels, abnormalities were only seen in the distal part of vessels; therefore, a thorough examination is warranted.
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Affiliation(s)
- Seyed Ali Alamdaran
- Akbar Children’s Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Shima Arjmand
- Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Reza Rahimzadeh Oskooei
- Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Son J, Lee S, Kim W, Jung SM, Jeon TY, Yoo SY, Kim JH, Seo JM. Abnormal Orientation of the Superior Mesenteric Vessels Detected in Asymptomatic Infants: What Is Its Destiny? Front Pediatr 2021; 9:665448. [PMID: 34178885 PMCID: PMC8226012 DOI: 10.3389/fped.2021.665448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 05/20/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Ultrasonography (USG) has been described as an alternative diagnostic tool for malrotation that evaluates the orientation of the superior mesenteric vessels. However, literature concerning the management of patients who do not have abdominal symptoms is limited. We aimed to review the clinical course of infants showing abnormal orientation of the superior mesenteric vessels on USG who were asymptomatic at the time of diagnosis. Methods: Seventy asymptomatic infants with abnormal orientation of the superior mesenteric vessels in a single center between 2014 and 2018 were retrospectively analyzed. Results: The 70 patients, 21 underwent upper gastrointestinal series (UGIS) and 11 underwent abdominal surgery for other surgical conditions. Among the 32 (45.7%) patients who underwent UGIS or abdominal surgery, 11 were proven to have malrotation. Of the 38 (54.3%) patients who did not undergo UGIS or abdominal surgery, six patients were too unstable to undergo UGIS, five died due to cardiac complications, and the remaining patient developed midgut volvulus and died 3 days after emergency surgery. The remaining 32 patients who did not undergo UGIS or abdominal surgery were discharged without additional tests, and all were asymptomatic until their last follow-up. In the multivariate analysis, history of heart surgery and the presence of more than three anomalies were significantly associated with malrotation. Conclusion: A significant number of malrotation were diagnosed in asymptomatic infants with abnormal orientation of the superior mesenteric vessels on USG. Infants with major cardiac or multiple anomalies need special attention and should undergo UGIS in a promptly manner to confirm malrotation.
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Affiliation(s)
- Joonhyuk Son
- Department of Pediatric Surgery, Hanyang University College of Medicine, Seoul, South Korea
| | - Sanghoon Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Wontae Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Soo-Min Jung
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Tae Yeon Jeon
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - So-Young Yoo
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ji Hye Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jeong-Meen Seo
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Zhang W, Sun H, Luo F. The efficiency of sonography in diagnosing volvulus in neonates with suspected intestinal malrotation. Medicine (Baltimore) 2017; 96:e8287. [PMID: 29049228 PMCID: PMC5662394 DOI: 10.1097/md.0000000000008287] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
This study is to prospectively evaluate the efficiency of sonography for volvulus diagnosis in neonates with clinically suspected intestinal malrotation.A total of 83 patients with suspected intestinal malrotation who underwent detailed abdominal sonography and upper gastrointestinal contrast study were included. Malrotation was characterized by inversion of the superior mesenteric artery (SMA) and superior mesenteric vein (SMV) in sonographic examination. The "whirlpool sign" of Color Doppler Sonography was recognized as a characteristic for malrotation with volvulus. The degrees of rotation of the SMV winding around SMA were also detected by sonography. Surgery was performed in patients with sonography diagnosed malrotation.A total of 39 patients were sonographically diagnosed as malrotation which was subsequently confirmed by surgery. The sensitivity and positive predictive value of the sonographic diagnosis were both 100% (39/39). The sensitivity, specificity and accuracy of "whirlpool sign" for the detection of midgut volvulus were 95.2% (20/21), 88.9% (16/18), and 92.3% (36/39), respectively. Greater degrees of rotation (equal or greater than 720°) showed higher risk (odds ratio, 5.0; P < .01) for intestinal necrosis occurrence.Sonography is more accurate in diagnosing suspected malrotation than upper gastrointestinal contrast study. Specific sonographic "whirlpool sign" related to volvulus may be used as a potential indicator for intestinal necrosis. In addition, sonography can exclude malrotation and may help the diagnosis of other diseases, such as annular pancreas and duodenal atresia.
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Birajdar S, Rao SC, Bettenay F. Role of upper gastrointestinal contrast studies for suspected malrotation in neonatal population. J Paediatr Child Health 2017; 53:644-649. [PMID: 28425590 DOI: 10.1111/jpc.13515] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 12/19/2016] [Accepted: 12/28/2016] [Indexed: 11/28/2022]
Abstract
AIM Upper gastrointestinal (UGI) contrast study is the preferred radiological investigation to diagnose malrotation of intestine. We aimed to review the role of UGI contrast in neonates (term and preterm) who were clinically suspected to have malrotation. METHODS The study included a retrospective review of medical charts and radiology reports. RESULTS A total of 164 newborn infants underwent UGI contrast study to rule out malrotation during the study period (2006-2015). Median gestational age at the time of presentation was 38 weeks (interquartile range: 35.5-39.6 weeks). Median age for clinical presentation was day 2 of life (interquartile range: 2-5 days). Out of the 164 contrast studies, 112 were normal, whereas 52 were reported to have malrotation. Of those 52 infants, 47 were confirmed to have malrotation on surgery (positive predictive value: 90). Of the 112 infants with normal UGI contrasts, nine infants underwent laparotomy for ongoing clinical symptoms out of which four infants were diagnosed to have malrotation on laparotomy. There were 22 infants born at gestational age <32 weeks, who underwent UGI contrast studies to rule out malrotation. Their clinical symptoms were similar to necrotising enterocolitis. Of 22 preterm contrast studies, six were reported to have malrotation; of these, five had surgically confirmed malrotation. No complications related to the contrast study were noted in both term and preterm infants. CONCLUSION Current study reaffirms the role of UGI contrast study as the investigation of choice for diagnosis of malrotation, in both term and preterm infants. UGI contrast is safe and well tolerated even in preterm infants.
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Affiliation(s)
- Suresh Birajdar
- Department of Neonatology, Princess Margaret Hospital for Children, Perth, Western Australia, Australia.,Department of Neonatology, King Edward Memorial Hospital for Women, Perth, Western Australia, Australia
| | - Shripada C Rao
- Department of Neonatology, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
| | - Fiona Bettenay
- Department of Diagnostic Imaging, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
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Khen-Dunlop N, Beaudoin S, Marion B, Rousseau V, Giuseppi A, Nicloux M, Grevent D, Salomon LJ, Aigrain Y, Lapillonne A, Sarnacki S. Segmental volvulus in the neonate: A particular clinical entity. J Pediatr Surg 2017; 52:454-457. [PMID: 28443816 DOI: 10.1016/j.jpedsurg.2016.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 10/03/2016] [Accepted: 10/04/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Complete intestinal volvulus is mainly related to congenital anomalies of the so-called intestinal malrotation, whereas segmental volvulus appears as a distinct entity, mostly observed during the perinatal period. Because these two situations are still lumped together, the aim of this study was to describe the particular condition of neonatal segmental volvulus. STUDY DESIGN We analyzed the circumstances of diagnosis and management of 17 consecutives neonates operated for segmental volvulus more than a 10-year period in a single institution. During the same period, 19 cases of neonatal complete midgut volvulus were operated. RESULTS Prenatal US exam anomalies were observed in 16/17 (94%) of segmental volvulus, significantly more frequently than in complete volvulus (p=0.003). Intestinal malposition was described peroperatively in all cases of complete volvulus, but also in 4/17 segmental volvulus (23%). Intestinal resection was performed in 88% of segmental volvulus when only one extensive intestinal necrosis was observed in complete volvulus. Parenteral nutrition was required in all patients with segmental volvulus with a median duration of 50days (range 5-251). CONCLUSION Segmental volvulus occurs mainly prenatally and leads to fetal ultrasound anomalies. This situation, despite a limited length of intestinal loss, is associated to significant postnatal morbidity. TYPE OF THE STUDY Treatment study. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Naziha Khen-Dunlop
- AP-HP, Hôpital Necker-Enfants malades, Service de Chirurgie Pédiatrique Viscérale, Paris, France; Université Paris Descartes, Paris, France; EA 7328 FETUS, Hôpital Necker-Enfants malades, Paris, France.
| | - Sylvie Beaudoin
- AP-HP, Hôpital Necker-Enfants malades, Service de Chirurgie Pédiatrique Viscérale, Paris, France; Université Paris Descartes, Paris, France
| | - Blandine Marion
- AP-HP, Hôpital Necker-Enfants malades, Service de Chirurgie Pédiatrique Viscérale, Paris, France
| | - Véronique Rousseau
- AP-HP, Hôpital Necker-Enfants malades, Service de Chirurgie Pédiatrique Viscérale, Paris, France
| | - Agnes Giuseppi
- AP-HP, Hôpital Necker-Enfants malades, Service de Néonatalogie, Paris, France
| | - Muriel Nicloux
- AP-HP, Hôpital Necker-Enfants malades, Service de Néonatalogie, Paris, France
| | - David Grevent
- AP-HP, Hôpital Necker-Enfants malades, Service de Radiologie Pédiatrique, Paris, France
| | - Laurent J Salomon
- AP-HP, Hôpital Necker-Enfants malades, Maternité, Paris, France; Université Paris Descartes, Paris, France; EA 7328 FETUS, Hôpital Necker-Enfants malades, Paris, France
| | - Yves Aigrain
- AP-HP, Hôpital Necker-Enfants malades, Service de Chirurgie Pédiatrique Viscérale, Paris, France; Université Paris Descartes, Paris, France
| | - Alexandre Lapillonne
- AP-HP, Hôpital Necker-Enfants malades, Service de Néonatalogie, Paris, France; Université Paris Descartes, Paris, France
| | - Sabine Sarnacki
- AP-HP, Hôpital Necker-Enfants malades, Service de Chirurgie Pédiatrique Viscérale, Paris, France; Université Paris Descartes, Paris, France
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Kumar B, Kumar M, Kumar P, Sinha AK, Anand U, Kumar A. Color Doppler-An effective tool for diagnosing midgut volvulus with malrotation. Indian J Gastroenterol 2017; 36:27-31. [PMID: 28124311 DOI: 10.1007/s12664-017-0729-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Accepted: 01/05/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Malrotation with midgut volvulus is a common surgical emergency in children. A diagnostic tool for malrotation with characteristics ideal in emergency settings such as non-invasiveness and rapidity remains a keenly debated issue among surgeons and radiologists alike. METHODS Fifty-two pediatric patients of suspected malrotation with midgut volvulus were studied between 1998 and 2016. All patients underwent plain abdominal X-ray and Color Doppler; contrast upper gastrointestinal (GI) studywas done in some patients. All cases were operated and diagnosis was confirmed. A subset of 60 pediatric patients with nonspecific GI complaints were also examined to see relative position of superior mesenteric vein (SMV)/superior mesenteric artery (SMA) in control population. RESULT A total of 52 suspected cases of malrotation were admitted from May 1998 to November 2015, 43 had inversion of SMA/SMV and nine had SMV anterior of SMA in Color Doppler. All 43 cases of inversion of SMA/SMV were cases of malrotation after surgical confirmation; while five out of nine cases of SMV anterior to SMA had malrotation. CONCLUSION In appropriate clinical settings, Color Doppler documenting the reversal or aberrant SMV/SMA axis is not only predictive but also diagnostic of malrotation of gut.
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Affiliation(s)
- Bindey Kumar
- Department of Pediatric Surgery, All India Institute of Medical Sciences, Phulwari Sharif, Patna, 801 507, India
| | - Manish Kumar
- Department of Pediatrics, All India Institute of Medical Sciences, Phulwari Sharif, Patna, 801 507, India.
| | - Prem Kumar
- Department of Radiology, All India Institute of Medical Sciences, Phulwari Sharif, Patna, 801 507, India
| | - Amit Kumar Sinha
- Department of Pediatric Surgery, All India Institute of Medical Sciences, Phulwari Sharif, Patna, 801 507, India
| | - Utpal Anand
- Department of Gastrosurgery, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna, 800 014, India
| | - Anil Kumar
- Department of Surgery, All India Institute of Medical Sciences, Phulwari Sharif, Patna, 801 507, India
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Ezer SS, Oguzkurt P, Temiz A, Ince E, Gezer HO, Demir S, Hicsonmez A. Intestinal malrotation needs immediate consideration and investigation. Pediatr Int 2016; 58:1200-1204. [PMID: 27353636 DOI: 10.1111/ped.13075] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2015] [Revised: 03/06/2016] [Accepted: 04/01/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND The aim of this study was to evaluate clinical presentation, diagnostic studies, and volvulus rate and to describe the unusual clinical clues of intestinal malrotation. METHODS A retrospective descriptive review was carried out of all patients diagnosed with intestinal malrotation between 2002 and 2014. Patients were divided into two groups: infants (≤1 year, n = 16; group 1); and children (>1 year, n = 12; group 2). Patient demographics, clinical history, symptoms, physical examination, diagnostic work-up, operative findings and early outcome were evaluated. RESULTS Bilious vomiting was the cardinal complaint in both groups. Unusual symptoms such as respiratory insufficiency, dehydration, afebrile convulsion, and lethargy were prominent symptoms in six patients in group 1, whereas history of frequent hospitalization due to recurrent abdominal pain and feeding intolerance were prominent in six patients in group 2. Midgut volvulus was identified in 15 patients, four of whom were in group 2. Standard Ladd's procedure was done in addition to correction of volvulus. CONCLUSION Malrotation with or without midgut volvulus is not a rare condition and should be kept in mind for any age group. Specific signs of diagnosis are not easily identified. In the case of unusual clinical presentation, diagnosis may be delayed and can result in catastrophic consequences if intestinal perfusion occurs. Although midgut volvulus is seen most frequently in infants, risk and complication rate are high beyond 1 year of age as well, and can manifest as failure to thrive, food intolerance, and abdominal pain needing recurrent hospitalization. Diagnostic suspicion and interdisciplinary coordination are essential for timely diagnosis and surgical treatment.
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Affiliation(s)
- Semire Serin Ezer
- Department of Pediatric Surgery, Başkent University, Faculty of Medicine, Ankara, Turkey
| | - Pelin Oguzkurt
- Department of Pediatric Surgery, Başkent University, Faculty of Medicine, Ankara, Turkey
| | - Abdulkerim Temiz
- Department of Pediatric Surgery, Başkent University, Faculty of Medicine, Ankara, Turkey
| | - Emine Ince
- Department of Pediatric Surgery, Başkent University, Faculty of Medicine, Ankara, Turkey
| | - Hasan Ozkan Gezer
- Department of Pediatric Surgery, Başkent University, Faculty of Medicine, Ankara, Turkey
| | - Senay Demir
- Department of Radiology, Başkent University, Faculty of Medicine, Ankara, Turkey
| | - Akgun Hicsonmez
- Department of Pediatric Surgery, Başkent University, Faculty of Medicine, Ankara, Turkey
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Teele SA, Jacobs JP, Border WL, Chanani NK. Heterotaxy Syndrome: Proceedings From the 10th International PCICS Meeting. World J Pediatr Congenit Heart Surg 2016; 6:616-29. [PMID: 26467876 DOI: 10.1177/2150135115604470] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A session dedicated to heterotaxy syndrome was included in the program of the Tenth International Conference of the Pediatric Cardiac Intensive Care Society in Miami, Florida in December 2014. An invited panel of experts reviewed the anatomic considerations, surgical considerations, noncardiac issues, and long-term outcomes in this challenging group of patients. The presentations, summarized in this article, reflect the current approach to this complex multiorgan syndrome and highlight future areas of clinical interest and research.
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Affiliation(s)
- Sarah A Teele
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jeffrey P Jacobs
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA Johns Hopkins All Children's Heart Institute, All Children's Hospital, Saint Petersburg and Tampa, FL, USA
| | - William L Border
- Sibley Heart Center Cardiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Nikhil K Chanani
- Sibley Heart Center Cardiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
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Zhou LY, Li SR, Wang W, Shan QY, Pan FS, Liu JC, Xie XY. Usefulness of Sonography in Evaluating Children Suspected of Malrotation: Comparison With an Upper Gastrointestinal Contrast Study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:1825-1832. [PMID: 26362146 DOI: 10.7863/ultra.14.10017] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 01/16/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES The purpose of this study was to prospectively evaluate the value of sonography in working up or ruling out malrotation by 3 sonographic features (inversion of the superior mesenteric artery and superior mesenteric vein, the whirlpool sign, and an intraperitoneal transverse duodenum) and comparing it with an upper gastrointestinal (GI) contrast study. METHODS A total of 70 pediatric patients who underwent detailed abdominal sonography to rule out intestinal malrotation were included. Twenty-three of them also underwent an upper GI contrast study. Surgery or clinical follow-up was taken as the reference standard. Statistical analysis was performed with the χ(2) test. RESULTS Twenty-three patients had a diagnosis of malrotation by surgical findings. With the combination of all 3 sonographic features, the sensitivity, specificity, and accuracy of sonography for determining malrotation were 100% (23 of 23), 97.8% (46 of 47), and 98.6% (69 of 70), respectively, whereas the sensitivity, specificity, and accuracy of the upper GI study were 40% (4 of 10), 64.3% (9 of 14), and 56.5% (13 of 23; P < .001). Combined anomalies in 2 patients and complications in 2 patients were also detected by sonography. CONCLUSIONS By combining inversion of the superior mesenteric artery and superior mesenteric vein, the whirlpool sign, and an intraperitoneal transverse duodenum, sonography might be more valuable for accurately working up or ruling out pediatric malrotation than an upper GI contrast study. In addition, sonography could provide extra information, such as combined anomalies and intestinal necrosis, to help management.
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Affiliation(s)
- Lu-yao Zhou
- Department of Medical Ultrasonics, Institute for Diagnostic and Interventional Ultrasound (L.Z., W.W., Q.S., F.P., X.X.) and Departments of Radiology (S.L.) and Pediatric Surgery (J.L.), First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shu-rong Li
- Department of Medical Ultrasonics, Institute for Diagnostic and Interventional Ultrasound (L.Z., W.W., Q.S., F.P., X.X.) and Departments of Radiology (S.L.) and Pediatric Surgery (J.L.), First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wei Wang
- Department of Medical Ultrasonics, Institute for Diagnostic and Interventional Ultrasound (L.Z., W.W., Q.S., F.P., X.X.) and Departments of Radiology (S.L.) and Pediatric Surgery (J.L.), First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Quan-yuan Shan
- Department of Medical Ultrasonics, Institute for Diagnostic and Interventional Ultrasound (L.Z., W.W., Q.S., F.P., X.X.) and Departments of Radiology (S.L.) and Pediatric Surgery (J.L.), First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Fu-shun Pan
- Department of Medical Ultrasonics, Institute for Diagnostic and Interventional Ultrasound (L.Z., W.W., Q.S., F.P., X.X.) and Departments of Radiology (S.L.) and Pediatric Surgery (J.L.), First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jun-cheng Liu
- Department of Medical Ultrasonics, Institute for Diagnostic and Interventional Ultrasound (L.Z., W.W., Q.S., F.P., X.X.) and Departments of Radiology (S.L.) and Pediatric Surgery (J.L.), First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiao-yan Xie
- Department of Medical Ultrasonics, Institute for Diagnostic and Interventional Ultrasound (L.Z., W.W., Q.S., F.P., X.X.) and Departments of Radiology (S.L.) and Pediatric Surgery (J.L.), First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
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Abstract
OBJECTIVES Midgut volvulus with malrotation is typical in newborns. We present our experience to emphasize the importance of suspecting midgut volvulus as a cause of abdominal pain also beyond infancy, particularly in relation to malrotation, and the relevance of ultrasonographic (US) signs in its diagnosis. METHODS A total of 34 patients (10 boys, 24 girls; ages between 1 day and 12 years) diagnosed as having malrotation or malrotation with volvulus, surgically confirmed, between 2006 and 2013 were retrospectively selected among all of the patients referred to our institution for acute abdomen and bilious vomiting. All of them underwent US and color Doppler examination before surgery. The US examinations were performed with 6 to 10 MHz microconvex and 7.5 to 10 Mhz linear transducer. The transducer was placed under xiphoid, and, with axial projection, the presence of anatomic position reversed between superior mesenteric vein (SMV) and superior mesenteric artery (SMA), as a sign of malrotation, and the presence of "whirlpool sign" (WS) (wrapping of the SMV and the mesentery around the SMA), as a sign of midgut volvulus, were evaluated. RESULTS In 27 of these 34 patients, midgut volvulus was present; 7 patients had intestinal malrotation. In 2 of 7 (28%) patients with malrotation, SMA and SMV were inverted. Among the patients with volvulus, 2 showed reversed vessel position and 22 patients presented the WS in association with SMA/SMV inversion (22/27, 81%). CONCLUSIONS Midgut volvulus with malrotation can appear beyond the neonatal age group as demonstrated in our case. The WS sign is sufficiently sensitive for its diagnosis and should be routinely researched at all ages of pediatric population. Anatomic inversion between SMV and SMA seems to be not enough sensitive in isolated malrotation diagnosis.
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Common and uncommon applications of bowel ultrasound with pathologic correlation in children. AJR Am J Roentgenol 2014; 202:946-59. [PMID: 24758646 DOI: 10.2214/ajr.13.11661] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The purpose of this article is to describe the indications and techniques for bowel ultrasound for inflammatory bowel disease and other common and uncommon entities and describe and illustrate their imaging appearances, including endoscopic or surgical correlation. CONCLUSION Ultrasound is a useful tool for the evaluation of inflammatory bowel disease and many other bowel diseases. Radiologists must become familiar with the full potential of ultrasound in the evaluation of the bowel in children because the need for alternative radiation-free imaging techniques continues to grow.
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Saliakellis E, Borrelli O, Thapar N. Paediatric GI emergencies. Best Pract Res Clin Gastroenterol 2013; 27:799-817. [PMID: 24160935 DOI: 10.1016/j.bpg.2013.08.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Accepted: 08/21/2013] [Indexed: 01/31/2023]
Abstract
Paediatric GI emergencies constitute a wide range of gut pathologies ranging from those that are common, easily diagnosed and treated to conditions that are rarer, often more severe and challenging to manage. Among a myriad of ordinary clinical symptoms and signs physicians have to identify the child with a serious, life-threatening pathology and initiate the appropriate diagnostic and therapeutic pathway. The aim of the review is to present and discuss a selection of key paediatric GI emergencies that provide challenges in diagnosis and treatment. These conditions are classified by their presentation or pathogenesis and include inflammatory conditions, those presenting with GI obstruction or haemorrhage and the ingestion of foreign bodies or caustic substances. The most recent advances regarding the management of these entities are discussed along with key areas of clinical practice and future research.
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Affiliation(s)
- Efstratios Saliakellis
- Division of Neurogastroenterology and Motility, Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
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Alehossein M, Abdi S, Pourgholami M, Naseri M, Salamati P. Diagnostic accuracy of ultrasound in determining the cause of bilious vomiting in neonates. IRANIAN JOURNAL OF RADIOLOGY 2012; 9:190-4. [PMID: 23407700 PMCID: PMC3569550 DOI: 10.5812/iranjradiol.8465] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Revised: 09/04/2012] [Accepted: 09/08/2012] [Indexed: 12/26/2022]
Abstract
Background Plain radiography and contrast radiologic studies are traditionally the main options in evaluating neonates presenting with bilious vomiting. While ultrasonography (US) is more available, its diagnostic accuracy is in question. Objectives The purpose of this study is to determine the diagnostic accuracy of US in evaluating these patients with bilious vomiting. Patients and Methods All neonates with bilious vomiting or bilious nasogastric tube drainage presented to a children’s hospital in a 1.5-year period were included. US were performed in all patients. The results were compared with clinical and radiological data and the final diagnosis. We used chi-square and Fisher’s exact tests for analysis. Results The cause of bilious vomiting for 18 of the 23 included patients was surgical. All patients labeled as surgical candidates by US ended in surgery [positive predictive value (PPV) = 100%], while only 50% of the patients with inconclusive US were operated [negative predictive value (NPV) = 50%, Confidence Interval (CI) 95%: 29%-71%]. The sensitivity and specificity of US in diagnosing intestinal atresia (n = 9) was 89% [CI 95%: (68% - 100%)] and 100%. In cases with malrotation (n = 4) and midgut volvulus (n = 2), sonographic diagnosis was in concordance with final surgical diagnosis. Conclusion This study suggested that in cases in which US makes a certain diagnosis, its accuracy eliminates the need for further diagnostic tests, but if it is inconclusive, further radiological contrast studies should be tried to make the final diagnosis.
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Affiliation(s)
- Mehdi Alehossein
- Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Medical Imaging Center, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Department of Radiology, Bahrami Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Siamak Abdi
- Department of Neurology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Pourgholami
- Department of Radiology, Bahrami Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohsen Naseri
- Department of Pediatrics, Bahrami Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Payman Salamati
- Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Medical Imaging Center, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Corresponding author: Payman Salamati, Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Medical Imaging Center, Imam Khomeini Complex Hospital, Keshavarz Blvd., Tehran, Iran. Tel.: +98-2166581579, Fax: +98-2166581560, E-mail:
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Menten R, Reding R, Godding V, Dumitriu D, Clapuyt P. Sonographic assessment of the retroperitoneal position of the third portion of the duodenum: an indicator of normal intestinal rotation. Pediatr Radiol 2012; 42:941-5. [PMID: 22684229 DOI: 10.1007/s00247-012-2403-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Revised: 01/25/2012] [Accepted: 01/29/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND The diagnosis of intestinal malrotation is based on an upper gastrointestinal contrast series (UGI), which is considered the imaging reference standard. It may however be challenging even for experienced paediatric radiologists. OBJECTIVE The purpose of this study was to demonstrate the agreement between UGI and US in assessing the position of the third portion of the duodenum (D3) and to show that a retroperitoneal duodenum indicates normal forgut rotation. MATERIALS AND METHODS In a prospective study, US assessment of the duodenum and the superior mesenteric vessels was performed in consecutive children who were referred for clinically indicated UGI at a single institution. RESULTS Eighty-five children, 5 months to 14 years old, were studied. In 82/85 (96%), both US and UGI suggested normal forgut rotation. In three children, US demonstrated a normal position of the D3 whereas UGI showed an abnormal position of the duodeno-jejunal junction. CONCLUSION US is a non-invasive, easily performed technique for excluding malrotation. UGI may be reserved for situations where US does not demonstrate a normal position of the D3.
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Affiliation(s)
- Renaud Menten
- Paediatric Radiology Unit, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, Brussels 1200, Belgium.
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Abstract
OBJECTIVES Pediatric small-bowel volvulus (SBV) is a surgical emergency, and early diagnosis is difficult. We analyzed the clinical manifestations, imaging findings, and laboratory parameters in children with SBV and attempted to determine the risk factors for bowel gangrene. PATIENTS AND METHODS Forty-nine children (35 boys and 14 girls) with SBV who were admitted to the hospital for a period of 13 years were enrolled. Clinical and laboratory parameters and evaluation measures included fever, abdominal pain, vomiting, bloody stool, peritoneal signs, severe dehydration, disease duration, white blood cell counts, sugar, C-reactive protein (CRP), sodium, potassium, metabolic acidosis, blood urea nitrogen, and creatinine. These parameters were statistically compared between patients with and without bowel gangrene. RESULTS Thirty-six patients (73.5%) were 5 years old or younger, and nearly half were younger than 1 year old. Abdominal pain and vomiting were 2 major symptoms. Malrotation was the most common cause of SBV. In univariate analysis, nonbilious vomiting, peritoneal signs, severe dehydration, leukocytosis (WBC count >18,000 cells/mm3), elevated CRP (>50 mg/dL), and hyponatremia (<130 mmol/L) were significantly associated with bowel gangrene (P < 0.05). In multivariate analysis, nonbilious vomiting, leukocytosis, and elevated CRP were significantly (P < 0.05) associated with bowel gangrene. The resection rate for bowel gangrene was 44.9%, and no mortality was found. Seven (14.3%) patients had postoperative complications, including short-bowel syndrome (n = 2), adhesion ileus (n = 3), and intraabdominal abscess (n = 3). Seven experienced failure to thrive in later follow-up. CONCLUSIONS Specific clinical manifestations and laboratory parameters are helpful in the identification of bowel gangrene in children with SBV.
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Abstract
Abdominal pain is one of the most common reasons pediatric patients seek emergency care. The emergency physician must be able to distinguish diagnoses requiring immediate attention from self-limiting processes. Pediatric patients can be challenging, particularly those who are preverbal, and therefore, the clinician must rely on a detailed history from a parent or caregiver as well as a careful physical examination in order to narrow the differential diagnosis. This article highlights several pediatric diagnoses presenting as abdominal pain, including surgical emergencies, nonsurgical diagnoses, and extraabdominal processes, and reviews the clinical presentation, diagnostic evaluation, and management of each.
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Affiliation(s)
- Jennifer R Marin
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, PA 15224, USA.
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Assessment of retromesenteric position of the third portion of the duodenum: an US feasibility study in 33 newborns. Pediatr Radiol 2010; 40:1476-84. [PMID: 20552188 DOI: 10.1007/s00247-010-1709-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2009] [Revised: 04/29/2010] [Accepted: 05/05/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND US can be used to assess bowel and does not require ionizing radiation or the administration of contrast material. Prior studies of the duodenum with US are limited. OBJECTIVE This study assesses the success rate of US demonstration of the third portion of the duodenum (D3) between the superior mesenteric artery (SMA) and the aorta in newborns to exclude malrotation based on embryologic and anatomic principles. MATERIAL AND METHODS Thirty-three newborns underwent US studies. The structures between the SMA and the aorta, including D3, were evaluated in axial and longitudinal planes. The length of time to acquire diagnostic images was recorded. RESULTS In both the axial and longitudinal planes, D3 was seen between the SMA and the aorta in all 33 infants, including some with abundant bowel gas. The mean length of time to acquire diagnostic images was 34 s. CONCLUSION Bedside US successfully illustrated the retromesenteric position of D3 in all 33 infants. Overlying gas-filled bowel was effectively effaced by graded compression. The short study duration indicates the practicality of the method. Further studies in broader patient populations and in correlation with other imaging and/or surgical findings is required to validate our technique.
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Yousefzadeh DK. The position of the duodenojejunal junction: the wrong horse to bet on in diagnosing or excluding malrotation. Pediatr Radiol 2009; 39 Suppl 2:S172-7. [PMID: 19308381 DOI: 10.1007/s00247-008-1116-2] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE The purpose of this communication is to highlight the shortcomings of all currently used imaging criteria in diagnosing or excluding malrotation and offer ultrasound demonstration of the 3(rd) portion of the duodenum (D3) between the AO and the SMA in transverse and sagittal plains as the most reliable diagnostic method. BACKGROUND Although UGI is currently considered to be the imaging modality of choice in diagnosis of malrotations, numerous publications indicate that in certain patients, false positives and negatives can be encountered. MATERIALS AND METHODS The material consists of more than 10 years experience in university settings, during which the author has used US as the definitive imaging modality for the work-up of malrotation. High resolution linear transducers (5-17 MHz) are the transducers of choice. Imaging plains: A. Transverse. With gradual grading compression, the following landmarks are illustrated in cehaplocaudad directions in the following order. The junction of splenic vein with the SMV portal vein. The cross sections of SMA and SMV that may either be situated in midline, or to the right or the left of the midline. Left renal vein crossing the spine from left to right between the AO and the SMA. The jejunal vein, often coming from left, transversing between the AO and the SMA. The transverse portion of the duodenum, D3, between the AO & the SMA. B. Sagittal. D3 between vertically oriented SMA-SMV and the AO. If SMA is not aligned with the AO by slight compression on the right or the left side of the abdomen, it will be aligned (depending on leftward or rightward position of SMA-SMV in axial plain). Vertical orientation of SMA and SMV if they have an anteroposterior orientation. C. Coronal. Side by side orientation of SMA and SMV if they don't have an anteroposterior orientation. RESULTS In overwhelming majority of cases, by illustrating a retromesenteric D3 malrotation and, therefore, midgut volvulus were excluded. DISCUSSION None of the current imaging criteria addresses the following most fundamental anatomic and embryologic facts regarding the gut rotation and fixation. In first trimester, the D3 is secured in retroperitoneal space after the embryologic journey comes to an end, making the duodenum immune of midgut volvulus. The surgical pathology of malrotation-midgut volvulus indicates that D3 is always Intraperitoneal and has not reached its final embryologic destination in retroperitoneal space. Demonstrating a retromesenteric D3, therefore, indicates that the embryologic journey is completed and the patient does not have malrotation. Excluding malrotation excludes the likelihood of midgut volvus. CONCLUSION The position of the DJJ, the configuration of the duodenal sweep, the orientation of the mesenteric vessels are all wrong horses to bet on because none of them addresses the fundamental anatomic and embryologic facts. Only the cross-sectional imaging, US, CT and MRI can prove that the D3 is retromesenteric, therefore, excluding malrotation and volvulus. Therefore, demonstrating a retromesenteric duodenum is the reference standard of imaging in the work-up of malrotation, not any other previously published criteria. The US imaging is the most acceptable imaging method for malrotation work-up, in the spirit of ALARA principle and "Image Gently" campaign.
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Affiliation(s)
- David K Yousefzadeh
- Department of Radiology, The University of Chicago, Comer Children's Hospital, Chicago, IL 60637, USA.
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Lampl B, Levin TL, Berdon WE, Cowles RA. Malrotation and midgut volvulus: a historical review and current controversies in diagnosis and management. Pediatr Radiol 2009; 39:359-66. [PMID: 19241073 DOI: 10.1007/s00247-009-1168-y] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2008] [Revised: 12/09/2008] [Accepted: 01/14/2009] [Indexed: 01/27/2023]
Abstract
The complex and sometimes controversial subject of malrotation and midgut volvulus is reviewed commencing with the 19th-century Bohemian anatomist, Václav Treitz, who described the suspensory muscle anchoring of the duodenal-jejunal junction in the left upper quadrant, and continuing with William Ladd, the 20th-century American "father of pediatric surgery" who pioneered the surgical treatment of midgut volvulus. In this review, we present the interesting history of malrotation and discuss the current radiologic and surgical controversies surrounding its diagnosis and treatment. In the symptomatic patient with malrotation and possible midgut volvulus, prompt diagnosis is critical. The clinical examination and plain film are often confusing, and delayed diagnosis can lead to significant morbidity and death. Despite recent intense interest in the position of the mesenteric vessels on US and CT scans, the upper gastrointestinal series remains the fastest and most accurate method of demonstrating duodenal obstruction, the position of the ligament of Treitz, and, if the contrast agent is followed distally, cecal malposition. Controversy exists over the management of asymptomatic patients with malrotation in whom the diagnosis is made incidentally during evaluation for nonspecific complaints, prior to reflux surgery, and in those with heterotaxy syndromes.
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Affiliation(s)
- Brooke Lampl
- Department of Radiology, Columbia University College of Physicians and Surgeons, Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY 10032, USA
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A Midgut Malrotation with Entire Small Bowel Necrosis. POLISH JOURNAL OF SURGERY 2009. [DOI: 10.2478/v10035-009-0068-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Applegate KE, Anderson JM, Klatte EC. Intestinal malrotation in children: a problem-solving approach to the upper gastrointestinal series. Radiographics 2006; 26:1485-500. [PMID: 16973777 DOI: 10.1148/rg.265055167] [Citation(s) in RCA: 119] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Intestinal malrotation, which is defined by a congenital abnormal position of the duodenojejunal junction, may lead to midgut volvulus, a potentially life-threatening complication. An evaluation for malrotation is part of every upper gastrointestinal (GI) tract examination in pediatric patients, particularly neonates and infants. Although the diagnosis of malrotation is often straightforward, the imaging features in approximately 15% of upper GI tract examinations are equivocal and lead to a false-positive or false-negative interpretation. The clinical manifestations and upper GI tract findings of malrotation in older children and adults are less specific than are those in younger patients, and for this reason diagnosis of the condition may be more difficult. Successful differentiation between a normal variant and malrotation requires the use of optimal techniques in acquiring and interpreting the upper GI series. Familiarity with the upper GI series appearance of both normal and abnormal anatomic variants allows the radiologist to increase both diagnostic accuracy and confidence in the diagnosis of malrotation.
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Affiliation(s)
- Kimberly E Applegate
- Department of Radiology, Riley Hospital for Children, 702 Barnhill Dr, Room 1053B, Indianapolis, IN 46202, USA.
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de Silva NT, Young JA, Wales PW. Understanding neonatal bowel obstruction: building knowledge to advance practice. Neonatal Netw 2006; 25:303-18. [PMID: 16989130 DOI: 10.1891/0730-0832.25.5.303] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Providing care to neonates with bowel obstruction requires a basic understanding of gastrointestinal (GI) anatomy and functional landmarks as well as knowledge of the pathophysiology associated with intestinal blockage. Early recognition and prompt diagnosis necessitate astute assessment of common presenting symptoms and accurate interpretation of diagnostic investigations. Initial medical management is focused primarily on gastric decompression and maintenance of fluid and electrolyte balance. This article describes features of the neonatal GI tract and discusses common causes of neonatal bowel obstruction.
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Abstract
BACKGROUND Early diagnosis of malrotation can prevent fatal midgut volvulus. Abnormal orientation of the superior mesenteric artery (SMA) and vein (SMV) on ultrasonography (US) has been described in malrotation. We aimed to determine the accuracy of this technique. METHODS All children undergoing both upper gastrointestinal series (UGI) and US for possible malrotation over a 3-year period were reviewed. Patients were excluded if US did not include SMV/SMA orientation or if the duodenojejunal flexure was not visualized on UGI. RESULTS Of 211 eligible patients, UGI and US were both normal in 62% and both abnormal in 15%. Forty-four had abnormal US and normal UGI (false positive, 21%), and 5 patients had normal US and abnormal UGI (false negative, 2%). Of these 5, none were found to have a short mesenteric base, which put them at risk for volvulus. Among abnormal ultrasounds, inversion of SMV/SMA and a "whirlpool" sign were more predictive for malrotation and volvulus than anterior/posterior orientation. CONCLUSIONS Ultrasonography is a good screening tool that effectively rules out malrotation at risk for volvulus. Children with an abnormal ultrasound should have an UGI or go to the operating room, depending on clinical findings.
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Affiliation(s)
- Neil Orzech
- Department of Surgery, Hospital for Sick Children, Toronto, Ontario, Canada ON M5G 1X8
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Berrocal T, Gayá F, de Pablo L. Aspectos embriológicos, clínicos y radiológicos de la malrotación intestinal. RADIOLOGIA 2005. [DOI: 10.1016/s0033-8338(05)72843-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Coley BD. Pediatric applications of abdominal vascular Doppler: Part II. Pediatr Radiol 2004; 34:772-86. [PMID: 15300339 DOI: 10.1007/s00247-004-1227-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2004] [Revised: 04/19/2004] [Accepted: 05/03/2004] [Indexed: 10/26/2022]
Abstract
Ultrasound is a remarkably powerful and versatile modality for pediatric imaging, without requiring exposure to radiation or sedatives. By providing information on blood flow, Doppler sonography can reveal details about normal physiology and disease processes not discernable from gray-scale anatomic images alone. In part I, the basics of hemodynamics and effects on the Doppler waveform were discussed, along with clinical applications in hepatic disease. In part II, the application of Doppler in renal disease and in conditions affecting the deep abdominal vessels are discussed. The role of ultrasound contrast agents in pediatric Doppler imaging is briefly reviewed.
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Affiliation(s)
- Brian D Coley
- Department of Radiology, Columbus Children's Hospital, 700 Children's Dr, Columbus, OH 43205, USA.
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Abstract
The subject of malrotation and midgut volvulus in infancy and childhood is reviewed from the perspective of experience with 138 patients evaluated in a published series and a further 82 cases seen since. Embryology, historical aspects, clinical presentation, investigation, surgery, and outcome are discussed. The diagnosis of malrotation and volvulus should always be kept in mind when assessing any infant or child with symptoms of vomiting and pain, particularly when the vomiting is bile-stained. The diagnosis cannot be excluded if diarrhea is present, when clinical findings are bland, or even with normal abdominal radiographs. A contrast meal and follow-through should be done and, if correctly interpreted, should be diagnostic. Ultrasound examination may be helpful but is not secure enough to exclude the diagnosis. Laparotomy or laparoscopy is the only way to be sure. Malrotation with its propensity for volvulus is truly a time bomb lying within.
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Affiliation(s)
- A J W Millar
- Department of Paediatric Surgery, School of Child and Adolescent Health, University of Cape Town and Red Cross Children's Hospital, Rondesbosch, South Africa
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34
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Abstract
This article discusses how to investigate various surgical causes of vomiting. Particular emphasis is placed on plain radiographic, ultrasound, and contrast study findings. The article touches upon nineteen different diseases, and encompasses diseases found in neonates to adolescents.
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Affiliation(s)
- A C Maclennan
- Royal Hospital for Sick Children, Glasgow, Scotland, UK
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