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Yang X, Wang W, Wang K, Zhao J, Sun L, Jiang S, Wang Y, Feng W, Ding G, Fu T, Li A, Geng L. Identification and treatment of intestinal malrotation with midgut volvulus in childhood: a multicenter retrospective study. Front Pediatr 2024; 12:1390856. [PMID: 38803636 PMCID: PMC11128588 DOI: 10.3389/fped.2024.1390856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Accepted: 04/30/2024] [Indexed: 05/29/2024] Open
Abstract
Background Intestinal malrotation is a rare condition, and its delayed diagnosis can lead to fatal consequences. This study aimed to investigate the identification and treatment of malrotation in children. Methods Clinical data, imaging, operative findings, and early postoperative outcomes of 75 children with malrotation were retrospectively analyzed. Results The mean age was 6.18 ± 4.93 days and 51.26 ± 70.13 months in the neonatal group (56 patients) and non-neonatal group (19 patients), respectively. Sixty-seven patients were under the age of 1 year at the time of diagnosis. The occurrence of bilious vomiting and jaundice was significantly higher in the neonatal group (89.29%) than that in the non-neonatal group (37.5%), p < 0.05 and p < 0.01, respectively. The incidence of abnormal ultrasound (US) findings was 97.30% and 100%, respectively, and the sensitivities of the upper gastrointestinal series were 84.21% and 87.5%, respectively. Sixty-six (88%) patients had midgut volvulus, including in utero volvulus (two patients) and irreversible intestinal ischemia (four patients). Most neonates (89.29%) underwent open Ladd's procedure with a shorter operative time (p < 0.01). Reoperation was performed for postoperative complications (four patients) or missed comorbidities (two patients). Conclusions Non-bilious vomiting was the initial symptom in >10% of neonates and nearly 40% of non-neonates. This highlights the importance for emergency physicians and surgeons to be cautious about ruling out malrotation in patients with non-bilious vomiting. Utilizing US can obviate the need for contrast examinations owing to its higher diagnostic accuracy and rapid diagnosis and can be recommended as a first-line imaging technique. Additionally, open surgery is still an option for neonatal patients.
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Affiliation(s)
- Xiaofeng Yang
- Department of Pediatric Surgery, Binzhou Medical University Hospital, Binzhou, Shandong, China
| | - Wei Wang
- Department of Surgery, Maternity and Child Health Care of Zaozhuang, Zaozhuang, Shandong, China
| | - Kun Wang
- Department of Pediatric Surgery, The People’s Hospital of Rizhao, Rizhao, Shandong, China
| | - Jingquan Zhao
- Department of Surgery, Zibo Maternal and Child Health Hospital, Zibo, Shandong, China
| | - Liandong Sun
- Department of Pediatric Surgery, Binzhou Medical University Hospital, Binzhou, Shandong, China
| | - Shuai Jiang
- Department of Pediatric Surgery, Liaocheng People’s Hospital, Liancheng, Shandong, China
| | - Yewen Wang
- Department of Pediatric Surgery, Binzhou Medical University Hospital, Binzhou, Shandong, China
| | - Wenyu Feng
- Department of Pediatric Surgery, Binzhou Medical University Hospital, Binzhou, Shandong, China
| | - Guojian Ding
- Department of Pediatric Surgery, Binzhou Medical University Hospital, Binzhou, Shandong, China
| | - Tingliang Fu
- Department of Pediatric Surgery, Binzhou Medical University Hospital, Binzhou, Shandong, China
| | - Aiwu Li
- Department of Pediatric Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Lei Geng
- Department of Pediatric Surgery, Binzhou Medical University Hospital, Binzhou, Shandong, China
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Gerrie SK, Navarro OM. Imaging Features of Neonatal Bowel Obstruction. Radiographics 2023; 43:e230035. [PMID: 37471246 DOI: 10.1148/rg.230035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
Radiologic evaluation of neonatal bowel obstruction is challenging owing to the overlapping clinical features and imaging appearances of the most common differential diagnoses. The key to providing an appropriate differential diagnosis comes from a combination of the patient's gestational age, clinical features, and imaging findings. While assessment of radiographs can confirm bowel obstruction and indicate whether it is likely proximal or distal, additional findings at upper or lower gastrointestinal contrast study together with use of US are important in providing an appropriate differential diagnosis. The authors provide an in-depth assessment of the appearances of the most common differential diagnoses of proximal and distal neonatal bowel obstruction at abdominal radiography and upper and lower gastrointestinal contrast studies. These are divided into imaging patterns and their associated differential diagnoses on the basis of abdominal radiographic findings. These findings include esophageal atresia variants including the "single bubble," "double bubble," and "triple bubble" and distal bowel obstruction involving the small and large bowel. Entities discussed include esophageal atresia, hypertrophic pyloric stenosis, pyloric atresia, duodenal atresia, duodenal web, malrotation with midgut volvulus, jejunal atresia, ileal atresia, meconium ileus, segmental volvulus, internal hernia, colonic atresia, Hirschsprung disease, and functional immaturity of the large bowel. The authors include the advantages of abdominal US in this algorithm, particularly for hypertrophic pyloric stenosis, duodenal web, malrotation with midgut volvulus, and segmental volvulus. ©RSNA, 2023 Online supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.
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Affiliation(s)
- Samantha K Gerrie
- From the Department of Radiology, BC Children's Hospital, 4500 Oak St, Vancouver, BC, Canada V6H 3N1, and Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada (S.K.G.); and Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada, and Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada (O.M.N.)
| | - Oscar M Navarro
- From the Department of Radiology, BC Children's Hospital, 4500 Oak St, Vancouver, BC, Canada V6H 3N1, and Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada (S.K.G.); and Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada, and Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada (O.M.N.)
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Bollard KA, Valsenti G, Healey D, Murdoch J. The adequacy of fluoroscopic upper gastrointestinal studies for suspected intestinal volvulus in a tertiary care centre vs. secondary centres: A regional multicentre study. J Med Imaging Radiat Oncol 2021; 65:293-300. [PMID: 33634557 DOI: 10.1111/1754-9485.13156] [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: 11/09/2020] [Revised: 01/11/2021] [Accepted: 01/21/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Early diagnosis and treatment of intestinal volvulus are important to reduce morbidity. A fluoroscopic upper GI study is the gold standard for diagnosis and may be performed in a secondary or tertiary care centre prior to surgery. It is important the reporting radiologist is confident in the findings. We aim to assess whether there is any difference in confidence and study quality between paediatric and general radiologists who work in secondary or tertiary care centres. METHODS Retrospective review of initial radiology reports and blinded review of the study images by paediatric radiologists. RESULTS A total of 277 children underwent a fluoroscopic study for intestinal volvulus over a four-year period. The majority were performed at a tertiary care centre, by paediatric radiologists. The confidence of initial reporting was higher in paediatric than general radiologists despite whether they worked in a secondary or tertiary care centre (P-value < 0.001). On retrospective review, studies performed by paediatric radiologists were rated as having a higher confidence in identifying the location of the duodenojejunal flexure. General radiologists tended to have a slightly higher rate of repeat studies but still low at 2.2%. Despite this, there was no significant difference in the diagnosis rates and secondary centre general radiologists excluded malrotation in 62% of studies likely reducing transfer rates. CONCLUSION Confidence in initial reporting and on review of the duodenojejunal flexure location in suspected intestinal volvulus is higher in paediatric radiologists compared with general radiologists, although diagnosis rates are no different.
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Affiliation(s)
- Kate Amelia Bollard
- Department of Radiology, Wellington Regional Hospital, Wellington, New Zealand
| | - Gianluca Valsenti
- Department of Radiology, Wellington Regional Hospital, Wellington, New Zealand
| | - David Healey
- Department of Radiology, Wellington Regional Hospital, Wellington, New Zealand
| | - Jean Murdoch
- Department of Radiology, Wellington Regional Hospital, Wellington, New Zealand
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Deeg S, Krickeberg S, Nisar T, Schwarz-Bundy BD, Wessel L. Case Report: 7-Year-Old Boy with Incarcerated Internal Hernia Leading to Extensive Intestinal Necrosis Due to a Large Congenital Mesenteric Defect. KLINISCHE PADIATRIE 2021; 233:189-193. [PMID: 33465782 DOI: 10.1055/a-1306-1213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
We present a case of a 7-year-old boy with acute abdominal symptoms initially misdiagnosed as constipation. Delayed imaging diagnostics revealed an ileus with contorted small intestine, so laparotomy was indicated. An acute bowel obstruction was found based on an incarcerated internal hernia. Small and large bowel segments were incarcerated into a large mesenteric defect leading to extended intestinal necrosis. About 30 cm of necrotic small bowel and 15 cm of large intestine were resected, two primary anastomoses were performed. The mesenteric defect was closed with two running sutures. The boy's clinical outcome was very good. Two aspects are discussed: the initial clinical misdiagnosis of acute bowel obstruction in a child leading to a delay of diagnostics and therapy on the one hand and the origin of mesenteric defects on the other. In children with abdominal pain, ultrasound must be performed as soon as possible and pediatric surgeons have to be involved early. There should be an awareness of the fact, that mesenteric defects and other congenital malformations can occur more often than we suspect it. In the case of an internal hernia, a misjudgement of the clinical condition may be very harmful for the patient and can lead to a short bowel syndrome or even death.
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Affiliation(s)
- Susanne Deeg
- Kinderchirurgie, Klinikum Mannheim gGmbH Universitätsklinikum Medizinische Fakultät Mannheim der Universität Heidelberg, Mannheim, Germany
| | - Sophie Krickeberg
- Kinderchirurgie, Klinikum Mannheim gGmbH Universitätsklinikum Medizinische Fakultät Mannheim der Universität Heidelberg, Mannheim, Germany
| | - Tauseef Nisar
- Kinderchirurgie, Klinikum Mannheim gGmbH Universitätsklinikum Medizinische Fakultät Mannheim der Universität Heidelberg, Mannheim, Germany
| | - Bogata Dora Schwarz-Bundy
- Department of Radiology, Klinikum Mannheim gGmbH Universitätsklinikum Medizinische Fakultät Mannheim der Universitat Heidelberg, Mannheim, Germany
| | - Lucas Wessel
- Kinderchirurgie, Klinikum Mannheim gGmbH Universitätsklinikum Medizinische Fakultät Mannheim der Universität Heidelberg, Mannheim, Germany
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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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Kumbhar SS, Qi J. Fluoroscopic Diagnosis of Malrotation: Technique, Challenges, and Trouble Shooting. Curr Probl Diagn Radiol 2019; 49:476-488. [PMID: 31711685 DOI: 10.1067/j.cpradiol.2019.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 10/16/2019] [Indexed: 12/20/2022]
Abstract
A fluoroscopic upper gastrointestinal series is the most commonly used investigation for the diagnosis of malrotation and midgut volvulus. However, both false positive and false negative results can occur causing diagnostic confusion. Several physiologic states and pathologic conditions can mimic fluoroscopic appearance of malrotation. Proper fluoroscopic technique is essential to maximize diagnostic accuracy. In this pictorial essay, we discuss common diagnostic challenges in the diagnosis of malrotation and strategies radiologists can use to clarify the diagnosis in equivocal cases.
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Affiliation(s)
| | - Jing Qi
- Medical College of Wisconsin, Milwaukee, WI
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