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Mohamed Burhan MS, Hamid HA, Zaki FM, Ning CJ, Zainal IA, Ros IAC, Daud CZBC, Othman MYB, Hing EY. The performance of ultrasound and upper gastrointestinal study in diagnosing malrotation in children, with or without volvulus. Emerg Radiol 2024; 31:151-165. [PMID: 38289574 DOI: 10.1007/s10140-024-02201-9] [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: 11/17/2023] [Accepted: 01/09/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Rapid diagnosis is crucial for pediatric patients with midgut volvulus and malrotation to prevent serious complications. While the upper gastrointestinal study (UGIS) is the traditional method, the use of ultrasound (US) is gaining prominence. OBJECTIVES To assess the diagnostic sensitivity and specificity of US compared to UGIS for malrotation and midgut volvulus. METHODS A cross-sectional study was performed on 68 pediatric patients who underwent US and/or UGIS before surgery for suspected midgut volvulus or malrotation in Kuala Lumpur (PPUKM and HTA), referencing surgical outcomes as the gold standard. RESULTS US demonstrated a higher specificity (100%) than UGIS (83%) for diagnosing malrotation, with a slightly lower sensitivity (97% vs. 100%). For midgut volvulus, US surpassed UGIS in sensitivity (92.9% vs. 66.7%) while maintaining comparable specificity. The SMA/SMV criteria showed better sensitivity (91.1%) than the D3 assessment (78.9%) on US, though both had high specificity. CONCLUSION US is equivalent to UGIS for identifying malrotation and is more sensitive for detecting midgut volvulus, supporting its use as a primary diagnostic tool. The study advocates for combined US and UGIS when either yields inconclusive results, optimizing diagnostic precision for these conditions.
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Affiliation(s)
- Mohamad Sufian Mohamed Burhan
- Department of Radiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur, Malaysia
- Hospital Tunku Azizah, Ministry of Heath, Kuala Lumpur, Malaysia
| | - Hamzaini Abd Hamid
- Department of Radiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur, Malaysia
| | - Faizah Mohd Zaki
- Department of Radiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur, Malaysia
| | - Chai Jia Ning
- Department of Radiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur, Malaysia
| | - Isa Azzaki Zainal
- Department of Radiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur, Malaysia
| | - Izzat Arslan Che Ros
- Department of Radiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur, Malaysia
| | | | | | - Erica Yee Hing
- Department of Radiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia.
- Hospital Canselor Tuanku Muhriz, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur, Malaysia.
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Venkatakrishna SSB, Elsingergy M, Calle-Toro JS, Dennis R, Otero HJ, Andronikou S. Quality and Diagnosis on the Lateral View of Pediatric Upper Gastro-Intestinal Series. CHILDREN (BASEL, SWITZERLAND) 2024; 11:151. [PMID: 38397262 PMCID: PMC10887497 DOI: 10.3390/children11020151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/20/2023] [Accepted: 01/23/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND The standard imaging technique for the diagnosis of intestinal malrotation remains the upper gastro-intestinal series (UGIS). The lateral view is promoted as important for making a diagnosis. For this, the lateral view should be of adequate quality, and radiologists must know the normal appearance as well as the appearance of duodenal variants, as misdiagnosis may lead to unnecessary surgery. OBJECTIVE We aimed to evaluate the quality, findings including the prevalence of the "descending staircase" configuration and its correspondence to a diagnosis of duodenum redundum. MATERIALS AND METHODS This was a retrospective study and was conducted in a large tertiary children's hospital in the United States. A retrospective review of UGI fluoroscopy exams in children aged ≤ 18 years between January and December 2018 was performed by a pediatric radiologist. First, the lateral view images/cine-loops were assessed independently, followed by the anteroposterior (AP) view. The studies which were designated to have an adequate lateral view were evaluated for configuration of the duodenum and recorded as: normal, abnormal, or normal variant. Also, the presence of a descending staircase configuration was correlated with an AP view for a diagnosis of duodenum redundum. RESULTS A total of 26 children (26%) (males:16; females:10) with age range 0 to 16 years had adequate lateral views during UGI exams for inclusion. Of the 26, 18 (69%) were reported as normal, 7 (27%) were reported as having a descending staircase and 1 (4%) was reported as abnormal. The AP view demonstrated 2 abnormal studies (1 malrotation and 1 non-rotation), 6 duodenum redundum and 18 normal exams. The one abnormal lateral duodenum was confirmed as a non-rotation on AP view; the second patient with an abnormal AP view had a normal appearance on the lateral view. CONCLUSIONS A total of 26% of UGI studies had adequate lateral views for interpretation. Of these, nearly a quarter (23%) demonstrated the descending stair-case sign corresponding to a diagnosis of duodenum redundum on the AP view. If the lateral view had been used alone, there would have been a missed diagnosis in one patient.
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Affiliation(s)
| | - Mohamed Elsingergy
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Juan S. Calle-Toro
- Department of Radiology, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Rebecca Dennis
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Hansel J. Otero
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Savvas Andronikou
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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Calle-Toro JS, Elsingergy MM, Dennis R, Grassi D, Kidd M, Otero H, Andronikou S. Frequency of duodenal anatomical variants in neonatal and pediatric upper gastrointestinal tract series (UGI) and the influence of exam quality on diagnostic reporting of these. Clin Imaging 2022; 87:28-33. [DOI: 10.1016/j.clinimag.2022.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 04/05/2022] [Accepted: 04/08/2022] [Indexed: 11/29/2022]
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Messiahs BC, Pitcher RD. A digital audit of emergency upper gastrointestinal fluoroscopy workflow in children with bilious vomiting. SA J Radiol 2022; 26:2300. [PMID: 35402008 PMCID: PMC8991196 DOI: 10.4102/sajr.v26i1.2300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 12/05/2021] [Indexed: 11/28/2022] Open
Abstract
Background Bilious vomiting in children requires an urgent evaluation with upper gastrointestinal (UGI) fluoroscopy as it may herald life-threatening midgut malrotation with volvulus (MMWV). There are no published data available on the duration of time-critical UGI workflow steps. Objectives A digital audit of workflow in emergency UGI contrast studies performed on children with bile-stained vomiting at a large South African teaching hospital. Method A retrospective study was conducted from 01 May 2012 – 31 May 2019. A customised search of the institutional radiology information system (RIS) defined all children with bilious vomiting who underwent emergency UGI fluoroscopy. Extracted RIS timestamps were used to calculate the median duration of the ‘approval’, ‘waiting’, ‘study’ and ‘reporting’ times. One-way analysis of variance and Chi-squared tests assessed the association between key parameters and the duration of workflow steps, with 5% significance (p < 0.05). Results Thirty-seven patients (n = 37) with median age 0.8 months were included, of whom 20 (54%) had an abnormal C-loop. The median ‘total time’ from physician request to report distribution was 107 min (interquartile range [IQR]: 67−173). The median ‘approval’ (6 min; IQR: 1–15) and ‘reporting’ (38 min; IQR: 17–91) times were the shortest and longest workflow steps, respectively. Abnormal C-loops (p = 0.04) and consultant referrals (p = 0.03) were associated with shorter ‘approval’ times. The neonatal ‘waiting’ time was significantly longer than that for older patients (p = 0.02). Conclusion The modern RIS is an excellent tool for time-critical workflow analyses, which can inform interventions for improved service delivery.
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Affiliation(s)
- Bradley C Messiahs
- Division of Radiodiagnosis, Department of Medical Imaging and Clinical Oncology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Richard D Pitcher
- Division of Radiodiagnosis, Department of Medical Imaging and Clinical Oncology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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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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