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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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2
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Schiess DM, Sammer MBK, Sher AC, El-Ali AM, Onwuka EA, Huang X, Staggers KA, Nguyen HN. Impact of Focused Abdominal Ultrasound Utilization on Outcomes for Children With Midgut Volvulus. J Pediatr Surg 2024; 59:1101-1107. [PMID: 38418275 DOI: 10.1016/j.jpedsurg.2024.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 01/12/2024] [Accepted: 01/23/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND Ultrasound (US) is gaining acceptance for the evaluation of midgut volvulus in children. However, its impact on clinical outcomes is unknown. We aim to determine whether using US as a first-line modality changes imaging mobilization, time to surgery and re-feeding, length of stay, and frequency of bowel necrosis, short bowel syndrome, and death. METHODS An IRB-approved retrospective cohort study was performed at a tertiary pediatric institution. Eighty children with surgically confirmed midgut volvulus from 2014 to 2021 were compared before and after implementation of US as first-line imaging and based on the modality used to diagnose midgut volvulus. RESULTS Outcomes were not statistically different pre- versus post-implementation. Compared with patients who had UGI only, those who had US only or both had significantly quicker imaging mobilization (median: -33 min; 95% CI: -61.2, -4.8; p = 0.023 and median: -31 min; 95% CI: -58.5, -3.6; p = 0.028 respectively). Patients with US only were less likely to have bowel necrosis compared with those who had UGI only (9.1% versus 43.8%, p = 0.042). Patients who had US only or both were less likely to develop short bowel syndrome compared to UGI only (4.8% US only, 0% both, 40% UGI only; p = 0.027 for US only, p = 0.005 for both). CONCLUSIONS No statistically significant change in outcomes was found after implementation of US as first-line imaging for midgut volvulus. However, patients diagnosed with US only or US in combination with UGI had quicker imaging mobilization and decreased frequency of bowel necrosis and short bowel syndrome. Findings suggest that US has potential to improve patient outcomes. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Desi M Schiess
- Edward B. Singleton Department of Radiology, Texas Children's Hospital, 6701 Fannin St, Houston, TX, 77030, USA; Department of Radiology, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA.
| | - Marla B K Sammer
- Edward B. Singleton Department of Radiology, Texas Children's Hospital, 6701 Fannin St, Houston, TX, 77030, USA; Department of Radiology, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA
| | - Andrew C Sher
- Edward B. Singleton Department of Radiology, Texas Children's Hospital, 6701 Fannin St, Houston, TX, 77030, USA; Department of Radiology, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA
| | - Alexander M El-Ali
- Division of Pediatric Radiology, Department of Radiology, NYU Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Ekene A Onwuka
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, 6701 Fannin St, Houston, TX, 77030, USA; Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA
| | - Xiaofan Huang
- Dan L Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, One Baylor Plaza Suite 100D (BCM 451), Houston, TX, 77030, USA
| | - Kristen A Staggers
- Dan L Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, One Baylor Plaza Suite 100D (BCM 451), Houston, TX, 77030, USA
| | - HaiThuy N Nguyen
- Edward B. Singleton Department of Radiology, Texas Children's Hospital, 6701 Fannin St, Houston, TX, 77030, USA; Department of Radiology, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA
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Meshaka R, Leung G, Easty M, Giuliani S, Loukogeorgakis S, Perucca G, Watson TA. Ultrasound as the first line investigation for midgut malrotation: a UK tertiary centre experience. Clin Radiol 2024; 79:150-159. [PMID: 38007334 DOI: 10.1016/j.crad.2023.10.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/23/2023] [Accepted: 10/29/2023] [Indexed: 11/27/2023]
Abstract
AIM To present the first 22-months experience of transitioning to an ultrasound-first pathway for suspected midgut malrotation. MATERIALS AND METHODS An "ultrasound-first" imaging pathway was initiated in October 2021. Twenty-two-months later, a search was undertaken of all <1-year-old patients with "bilious", "malrotation," or "volvulus" as the imaging indication. Reports and images from upper gastrointestinal fluoroscopy (UGI) and ultrasound were reviewed, and diagnoses and outcomes were documented. RESULTS The search yielded 101 eligible cases between October 2021 and July 2023. Of the patients, 63/101 (62%) had both ultrasound and UGI: 47/63 (75%) ultrasound first, 16/63 (25%) UGI first. Thirty-one per cent (31/101) had ultrasound only and 7/70 (10%) UGI only. The pathway diagnosed 7/8 (88%) infants with midgut malrotation with or without volvulus and one infant who had an inconclusive ultrasound examination with a suspected an internal hernia and who was found to have malrotation volvulus at surgery. Twenty-one infants who had confidently normal ultrasound examinations and who also had UGI all had a normal duodenojejunal flexure position. Ultrasound detected alternative pathology in eight children. Duodenal visualisation improved with time: 6/15 (40%) in the first 6 months to 23/34 (68%) after the first year. CONCLUSION The transition to ultrasound as the first diagnostic test for midgut malrotation can be done safely and effectively in a UK centre, which previously relied solely on UGI.
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Affiliation(s)
- R Meshaka
- Radiology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK.
| | - G Leung
- Radiology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - M Easty
- Radiology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - S Giuliani
- Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - S Loukogeorgakis
- Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - G Perucca
- Radiology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - T A Watson
- Radiology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
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El-Ali AM, Ocal S, Hartwell CA, Goldberg JD, Li X, Prestano J, Kamity R, Martin L, Strubel N, Lala S. Factors associated with diagnostic ultrasound for midgut volvulus and relevance of the non-diagnostic examination. Pediatr Radiol 2023; 53:2199-2207. [PMID: 37589763 DOI: 10.1007/s00247-023-05727-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 07/18/2023] [Accepted: 07/18/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Few reports explore the frequency and factors associated with diagnostic ultrasound (US) for midgut volvulus. OBJECTIVE To evaluate predictive factors for diagnostic US for midgut volvulus and clinical outcomes of patients with non-diagnostic US. MATERIALS AND METHODS This retrospective study included infants imaged for midgut volvulus with US. Exams were rated as diagnostic (midgut volvulus present or absent) or non-diagnostic by a pediatric radiologist, and in cases of disagreement with the original report, an additional pediatric radiologist was the tie-breaker. For each exam, the following were recorded: age, weight, respiratory support, exam indication, sonographer experience, and gaseous dilated bowel loops on radiography. Logistic regression models with "stepwise" variable selection were used to investigate the association of diagnostic US for midgut volvulus with each of the independent variables. RESULTS One hundred nineteen patients were imaged. US was diagnostic in 74% (88/119) of patients. In subsets of patients presenting with bilious emesis or age <28 days, US was diagnostic in 92% (22/24) and 90% (53/59), respectively. Logistic regression suggested that symptom type (bilious vs other) was the best predictor of diagnostic US (type 3 P=0.02). Out of 26 patients with available radiographs, US was diagnostic in 92% (12/13) of patients without bowel dilation on radiographs compared to 62% (8/13) of patients with bowel dilation (P=0.16). Weight, respiratory support, and sonographer experience did not differ between groups. Two sick neonates, ages 2 days and 30 days, in whom the primary clinical concern was dropping hematocrit and sepsis, respectively, had non-diagnostic ultrasounds in the setting of bowel dilation on radiography. Both were found to have midgut volvulus at surgery and both expired. CONCLUSION US was most frequently diagnostic in patients with bilious emesis or age less than 28 days. Non-diagnostic US for midgut volvulus must prompt a predetermined follow-up strategy, such as an additional imaging study (e.g., upper GI series), particularly in a sick child, as non-diagnostic US may miss midgut volvulus.
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Affiliation(s)
- Alexander Maad El-Ali
- Division of Pediatric Radiology, Department of Radiology, NYU Grossman School of Medicine, 660 First Avenue, New York, NY, 10016, USA.
| | - Selin Ocal
- NYU Grossman School of Medicine, Long Island Campus, 660 First Avenue, New York, NY, 10016, USA
| | - C Austen Hartwell
- Division of Pediatric Radiology, Department of Radiology, NYU Grossman School of Medicine, 660 First Avenue, New York, NY, 10016, USA
| | - Judith D Goldberg
- Department of Statistics, NYU Grossman School of Medicine, 660 First Avenue, New York, NY, 10016, USA
| | - Xiaochun Li
- Department of Statistics, NYU Grossman School of Medicine, 660 First Avenue, New York, NY, 10016, USA
| | - Jaimelee Prestano
- Division of Pediatric Radiology, Department of Radiology, NYU Grossman School of Medicine, 660 First Avenue, New York, NY, 10016, USA
| | - Ranjith Kamity
- Division of Neonatology, Department of Pediatrics, NYU Long Island School of Medicine, 259 First Street, Mineola, NY, 11501, USA
| | - Laura Martin
- Division of Pediatric Surgery, Department of Surgery, NYU Langone Medical Center, 530 First Avenue, Suite 10W, New York, NY, 10016, USA
| | - Naomi Strubel
- Division of Pediatric Radiology, Department of Radiology, NYU Grossman School of Medicine, 660 First Avenue, New York, NY, 10016, USA
| | - Shailee Lala
- Division of Pediatric Radiology, Department of Radiology, NYU Grossman School of Medicine, 660 First Avenue, New York, NY, 10016, USA
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Olutoye OO, Hammond J, Gilley J, Beckman RM, Bulathsinghala M, Keswani SS, Davies J, Mazziotti MV, Donepudi R, Belfort MA, King A, Ketwaroo PM, Lee TC. Fetal malrotation with midgut volvulus: Prenatal diagnosis and planning. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2023; 93:102654. [PMID: 37292252 PMCID: PMC10249907 DOI: 10.1016/j.epsc.2023.102654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023] Open
Abstract
Introduction Malrotation of the intestinal tract is a congenital malformation commonly found either incidentally or after affected individuals develop signs and symptoms of intestinal obstruction. Malrotation is prone to midgut volvulus that can cause intestinal obstruction and lead to ischemia and necrosis requiring emergent surgical intervention. Rare instances of in utero midgut volvulus have been reported in the literature and carry a high mortality given the difficulty in establishing a diagnosis prior to development of signs of intestinal ischemia and necrosis. Advancements in imaging have made it possible to diagnose in utero malrotation earlier, raising the question of optimal timing of delivery, especially in cases of prenatally diagnosed midgut volvulus. In these cases, the risks of premature birth must be weighed against the risks of fetal intestinal ischemia and potential fetal demise. Case presentation This case report details an interesting presentation of intestinal malrotation with suspected midgut volvulus found on prenatal imaging at 33 weeks and 4 days' gestation. This prompted delivery of the infant at 34 weeks and 2 days' gestation with urgent operative management, within 3 hours of life, after diagnosis was confirmed postnatally. Intraoperatively, the infant was confirmed to have midgut volvulus without bowel ischemia, the intestines were reduced, and a Ladd procedure was performed without incident. The infant recovered postoperatively without complication, tolerated advancement to full volume feeds and was discharged on day of life 18. Conclusion Successful management of fetal malrotation with midgut volvulus may be accomplished by early access to a multi-disciplinary team of professionals, prompt postnatal confirmation of diagnosis, and urgent correction to minimize the risk of complications.
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Affiliation(s)
- Oluyinka O. Olutoye
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - J.D. Hammond
- Division of Neonatology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Jamie Gilley
- Division of Neonatology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Ross M. Beckman
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Division of Pediatric Surgery, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Marie Bulathsinghala
- Division of Neonatology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Sonya S. Keswani
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Jonathan Davies
- Division of Neonatology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Mark V. Mazziotti
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Division of Pediatric Surgery, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Roopali Donepudi
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Michael A. Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Alice King
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Division of Pediatric Surgery, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Pamela M. Ketwaroo
- Edward B. Singleton Department of Radiology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Timothy C. Lee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Division of Pediatric Surgery, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, USA
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6
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Youssfi M, Goncalves LF. Ultrasound for malrotation and volvulus - point. Pediatr Radiol 2022; 52:716-722. [PMID: 34633478 DOI: 10.1007/s00247-021-05154-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 05/10/2021] [Accepted: 07/12/2021] [Indexed: 11/28/2022]
Abstract
Upper gastrointestinal series is considered the gold standard imaging test to evaluate for malrotation and midgut volvulus. US has been explored for this purpose in recent years and has been shown to be a good alternative because of its relatively good accuracy, fast learning curve for sonographers and radiologists, as well as convenience for children, clinical staff and radiologists in the neonatal intensive care unit. In this article we describe our experience and review the evidence supporting the use of emergency US primarily to diagnose midgut volvulus as well as its use as a problem-solving tool for the diagnosis of malrotation. The examination technique, normal and abnormal findings are described, with emphasis on the whirlpool and superior mesenteric artery cutoff signs to diagnose midgut volvulus.
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Affiliation(s)
- Mostafa Youssfi
- Department of Radiology, Phoenix Children's Hospital, 1919 E. Thomas Road, Phoenix, AZ, 85016, USA.,Department of Child Health and Radiology, University of Arizona College of Medicine, Phoenix, AZ, USA.,Department of Radiology, Mayo Clinic, Phoenix, AZ, USA.,Department of Radiology, Creighton University, Phoenix, AZ, USA
| | - Luis F Goncalves
- Department of Radiology, Phoenix Children's Hospital, 1919 E. Thomas Road, Phoenix, AZ, 85016, USA. .,Department of Child Health and Radiology, University of Arizona College of Medicine, Phoenix, AZ, USA. .,Department of Radiology, Mayo Clinic, Phoenix, AZ, USA. .,Department of Radiology, Creighton University, Phoenix, AZ, USA.
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7
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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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Nguyen HN, Kulkarni M, Jose J, Sisson A, Brandt ML, Sammer MB, Pammi M. Ultrasound for the diagnosis of malrotation and volvulus in children and adolescents: a systematic review and meta-analysis. Arch Dis Child 2021; 106:1171-1178. [PMID: 33879472 PMCID: PMC8526644 DOI: 10.1136/archdischild-2020-321082] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 03/15/2021] [Accepted: 03/28/2021] [Indexed: 02/01/2023]
Abstract
CONTEXT Despite the advantages of ultrasound (US), upper gastrointestinal contrast series (UGI) remains the first-line diagnostic modality in the diagnosis of midgut malrotation and volvulus in children. OBJECTIVE Evaluate the diagnostic accuracy of US in the diagnosis of malrotation with or without volvulus in children and adolescents aged 0-21 years, compared with the reference standard (diagnosis by surgery, UGI, CT, MRI, and clinical follow-up individually or as a composite). DATA SOURCES We searched the electronic databases Ovid-MEDLINE, Embase, Scopus, CINAHL, and the Cochrane library in October 2019 and updated on 18 August 2020. STUDY SELECTION Studies evaluating the diagnostic performance of US for diagnosis of midgut malrotation with or without volvulus in children (0-21 years). DATA EXTRACTION AND SYNTHESIS The data were extracted independently by two authors and a bivariate model was used for synthesis. RESULTS Meta-analysis of 17 cohort or cross-sectional studies and 2257 participants estimated a summary sensitivity of 94% (95% CI 89% to 97%) and summary specificity of 100% (95% CI 97% to 100%) (moderate certainty evidence) for the use of US for the diagnosis of malrotation with or without midgut volvulus compared with the reference standard. Subgroup analysis and meta-regression revealed better diagnostic accuracy in malrotation not complicated by volvulus, in the neonatal population and enteric fluid administration before US. CONCLUSIONS Moderate certainty evidence suggests excellent diagnostic accuracy and coupled with the advantages, a strong case exists for the use of abdominal US as the first-line diagnostic test for suspected midgut malrotation with or without volvulus in children and adolescents.
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Affiliation(s)
- HaiThuy N. Nguyen
- Edward B. Singleton Department of Radiology, Texas Children’s Hospital, Houston, Texas, USA,Department of Radiology, Baylor College of Medicine, Houston, Texas, USA
| | - Madhulika Kulkarni
- Department of Pediatrics, Texas Children’s Hospital, Houston, Texas, USA,Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Houston, Texas, USA
| | - Jisha Jose
- Department of Pediatrics, Texas Children’s Hospital, Houston, Texas, USA,Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Houston, Texas, USA
| | - Amy Sisson
- The Texas Medical Center Library, Houston, Texas, USA
| | - Mary L. Brandt
- Department of Surgery, Children’s Hospital of New Orleans, Louisiana, USA,Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Marla B.K. Sammer
- Edward B. Singleton Department of Radiology, Texas Children’s Hospital, Houston, Texas, USA,Department of Radiology, Baylor College of Medicine, Houston, Texas, USA
| | - Mohan Pammi
- Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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Watts H, Harrison R, Graham-Evans K. Whirlpool sign on ultrasound imaging in a preterm infant with suspected malrotation volvulus. Arch Dis Child Fetal Neonatal Ed 2021; 106:441. [PMID: 33293277 DOI: 10.1136/archdischild-2020-320804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 11/13/2020] [Accepted: 11/17/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Hannah Watts
- Neonatal Intensive Care Unit, Portsmouth Hospitals NHS Trust, Portsmouth, Portsmouth, UK
| | - Rachael Harrison
- Department of Radiology, Portsmouth Hospitals NHS Trust, Portsmouth, Portsmouth, UK
| | - Kate Graham-Evans
- Neonatal Intensive Care Unit, Portsmouth Hospitals NHS Trust, Portsmouth, Portsmouth, UK
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Xiong Z, Shen Y, Morelli JN, Li Z, Hu X, Hu D. CT facilitates improved diagnosis of adult intestinal malrotation: a 7-year retrospective study based on 332 cases. Insights Imaging 2021; 12:58. [PMID: 33929625 PMCID: PMC8087751 DOI: 10.1186/s13244-021-00999-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 04/21/2021] [Indexed: 12/17/2022] Open
Abstract
Objective To classify adult intestinal malrotation by CT. Methods This retrospective study enrolled adults diagnosed with intestinal malrotation who underwent abdominal CT at our institution between June 1, 2013, and August 30, 2020. All patients’ clinical information was recorded. Patients were divided into groups undergoing surgical and conservative management. The duodenum (nonrotation, partial rotation, and malrotation), jejunum, cecum, and the superior mesenteric artery/superior mesenteric vein relationship were reviewed on the CT images of each patient, and classification criteria developed based on the first three items. For each patient, each item was assessed separately by three radiologists. Consensus was required from at least two of them. Results A total of 332 eligible patients (218 men and 114 women; mean age 51.0 ± 15.3 years) were ultimately included and classified into ten types of malrotation. Duodenal partial rotation was present in most (73.2%, 243/332) with only 25% (83/332) demonstrating nonrotation. The jejunum was located in the right abdomen in 98.2% (326/332) of cases, and an ectopic cecum was found in only 12% (40/332, 29 cases with a left cecum, 7 pelvic, and 4 at midline). Asymptomatic patients comprised 56.6% (188/332) of cases, much higher than that in previous studies (17%, n = 82, p < .001), comprised mainly of patients with duodenal partial rotation (80.3%, 151/188). In 91 patients with detailed clinical data available (12 managed surgically and 79 conservatively), a significant difference in malrotation CT categorization was identified (p = .016). Conclusions CT enables greater detection of asymptomatic intestinal malrotation, enabling classification into multiple potentially clinically relevant subtypes. Supplementary Information The online version contains supplementary material available at 10.1186/s13244-021-00999-3.
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Affiliation(s)
- Ziman Xiong
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Qiaokou District, Wuhan, 430030, Hubei, China
| | - Yaqi Shen
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Qiaokou District, Wuhan, 430030, Hubei, China.
| | - John N Morelli
- Department of Radiology, St. John's Medical Center, Tulsa, OK, USA
| | - Zhen Li
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Qiaokou District, Wuhan, 430030, Hubei, China
| | - Xuemei Hu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Qiaokou District, Wuhan, 430030, Hubei, China
| | - Daoyu Hu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Qiaokou District, Wuhan, 430030, Hubei, China
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11
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Nguyen HN, Navarro OM, Guillerman RP, Silva CT, Sammer MBK. Untwisting the complexity of midgut malrotation and volvulus ultrasound. Pediatr Radiol 2021; 51:658-668. [PMID: 33398405 DOI: 10.1007/s00247-020-04876-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 08/27/2020] [Accepted: 10/08/2020] [Indexed: 01/20/2023]
Abstract
Abdominal US is emerging as an alternative to the upper gastrointestinal (GI) series as the preferred diagnostic imaging test for midgut malrotation complicated by volvulus. Unlike the upper GI series, US is free from ionizing radiation, does not require oral contrast agent, and can be performed portably and at times remotely from the interpreting radiologist, expediting diagnosis. Although some institutions do not have a standardized US protocol for midgut volvulus, many routinely use US in the setting of an infant or child with acute abdominal signs or symptoms to evaluate for common conditions such as hypertrophic pyloric stenosis, intussusception, necrotizing enterocolitis and appendicitis. Because these common conditions can overlap in age and clinical presentation with midgut volvulus, the aim of this pictorial essay is to provide instruction on the technique and diagnostic findings of midgut volvulus on US to ensure confident, accurate interpretation, and prompt treatment.
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Affiliation(s)
- HaiThuy N Nguyen
- Singleton Department of Radiology, Texas Children's Hospital, 6701 Fannin St., Houston, TX, 77030, USA. .,Department of Radiology, Baylor College of Medicine, Houston, TX, USA.
| | - Oscar M Navarro
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - R Paul Guillerman
- Singleton Department of Radiology, Texas Children's Hospital, 6701 Fannin St., Houston, TX, 77030, USA.,Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Cicero T Silva
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Marla B K Sammer
- Singleton Department of Radiology, Texas Children's Hospital, 6701 Fannin St., Houston, TX, 77030, USA.,Department of Radiology, Baylor College of Medicine, Houston, TX, USA
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12
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Strouse PJ. Ultrasound for malrotation and volvulus: has the time come? Pediatr Radiol 2021; 51:503-505. [PMID: 33404784 DOI: 10.1007/s00247-020-04919-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/09/2020] [Accepted: 11/17/2020] [Indexed: 01/12/2023]
Affiliation(s)
- Peter J Strouse
- Section of Pediatric Radiology,C. S. Mott Children's Hospital, Room 3-231,, Department of Radiology, Michigan Medicine, 1540 E. Hospital Drive, Ann Arbor, MI 48109-4252, USA.
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13
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Cheng YJ, Duh YC, Lin CH, Lien CH, Chen JJ, Lee HC, Lin CY. Sonographic whirlpool sign in neonatal intestinal volvulus. Pediatr Neonatol 2020; 61:653-654. [PMID: 32826203 DOI: 10.1016/j.pedneo.2020.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 06/03/2020] [Accepted: 07/01/2020] [Indexed: 11/18/2022] Open
Affiliation(s)
- Yu-Jyun Cheng
- Department of Pediatrics, Hsinchu MacKay Memorial Hospital, Hsinchu City, Taiwan
| | - Yih-Cherng Duh
- Department of Pediatric Surgery, Hsinchu Mackay Memorial Hospital, Hsinchu City, Taiwan
| | - Chao-Hsu Lin
- Department of Pediatrics, Hsinchu MacKay Memorial Hospital, Hsinchu City, Taiwan; Department of Biological Science and Technology, National Chiao-Tung University, Hsinchu City, Taiwan
| | - Chi-Hone Lien
- Department of Pediatrics, Hsinchu MacKay Memorial Hospital, Hsinchu City, Taiwan
| | - Jeng-Jung Chen
- Department of Pediatrics, Hsinchu MacKay Memorial Hospital, Hsinchu City, Taiwan; Department of Biological Science and Technology, National Chiao-Tung University, Hsinchu City, Taiwan
| | - Hung-Chang Lee
- Department of Pediatrics, MacKay Children's Hospital, Taipei, Taiwan; Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - Chien-Yu Lin
- Department of Pediatrics, Hsinchu MacKay Memorial Hospital, Hsinchu City, Taiwan; Department of Medicine, MacKay Medical College, New Taipei City, Taiwan.
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14
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15
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Sloan K, Alzamrooni A, Stedman FE, Ron O, Hall NJ. Diagnostic laparoscopy to exclude malrotation following inconclusive upper gastrointestinal contrast study in infants. Pediatr Surg Int 2020; 36:1221-1225. [PMID: 32803428 DOI: 10.1007/s00383-020-04729-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/05/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE We report the use of diagnostic laparoscopy as an alternative to laparotomy in the investigation of infants with clinical features concerning for malrotation and inconclusive upper gastrointestinal contrast study. METHOD Case note review of all infants in whom laparoscopy was performed during 2016-2020 to investigate for possible malrotation. RESULTS Eight infants were identified. All presented with acute clinical features of malrotation (bilious vomit) without evidence of an alternate explanatory diagnosis. All underwent upper gastrointestinal contrast study, with three also undergoing abdominal ultrasound. The radiological examinations could not exclude malrotation and all proceeded to laparoscopy. At laparoscopy, the small intestine was run to exclude the presence of midgut volvulus. In six cases, normal rotation was confirmed and no abnormal pathology was found. Two proceeded to laparotomy and underwent correction of malrotation. All infants recovered without complication. CONCLUSION Laparoscopy is an excellent modality for further investigation of infants presenting acutely in whom intestinal malrotation cannot be formally excluded radiologically. The positive identification of the DJ flexure and cecum in correct anatomical sites, both fixed to the posterior abdominal wall, provides adequate reassurance of low risk of volvulus and avoids a full laparotomy. We recommend diagnostic laparoscopy in cases of inconclusive upper gastrointestinal contrast study.
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Affiliation(s)
- K Sloan
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK.
| | - A Alzamrooni
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK
| | - F E Stedman
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK
| | - O Ron
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK
| | - N J Hall
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK.,University Surgery Unit, Faculty of Medicine, University of Southampton, Southampton, UK
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16
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The pediatric gastrointestinal tract: ultrasound findings in acute diseases. J Ultrasound 2019; 22:409-422. [PMID: 30758808 DOI: 10.1007/s40477-018-00355-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 12/15/2018] [Indexed: 02/07/2023] Open
Abstract
The study of the gastrointestinal tract by imaging, particularly using ultrasound, is a required instrument for diagnosis of acute and chronic gastrointestinal pathologies in pediatric age. Actually, ultrasound plays an increasing role in the evaluation of gastrointestinal tract in neonatal and pediatric patients because of their small body habitus and the presence of less fat tissue in the abdominal wall and peritoneal cavity. Ultrasound has certain advantages, thanks to the new wide-spectrum frequency probes able to assess a detailed study of the morphological aspects and functional characteristics of bowel loops, adding a new dimension to the imaging of this body system. In this paper, we review anatomy, ultrasound technique and sonographic findings of bowel pathology frequently encountered in neonatal and pediatric emergency setting.
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17
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Chandler C, Fisher KL. Sonographic Findings of Midgut Malrotation With Volvulus: A Case of Upper Intestinal Obstruction in a Neonate. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2018. [DOI: 10.1177/8756479317754054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Midgut malrotation is a congenital condition resulting from incomplete normal intestinal rotation after physiologic gut herniation. While it can remain asymptomatic over an entire lifetime, midgut volvulus is most likely to occur during early life. While an upper gastrointestinal series is the imaging modality of choice for definitive diagnosis, sonography is a safe and effective modality capable of indicating midgut malrotation, especially in pediatric patients. This case study illustrates the sonographic findings associated with intestinal malrotation with volvulus and discusses the etiology, signs, symptoms, and treatment of the condition. In addition, the sonographic findings are correlated with upper gastrointestinal results, which confirmed midgut malrotation. The diagnosis of volvulus secondary to midgut malrotation was confirmed by a laparoscopic Ladd procedure performed to treat the neonate.
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Affiliation(s)
- Courtney Chandler
- Diagnostic Medical Ultrasound Program, University of Missouri, Columbia, MO, USA
| | - Kelsy L. Fisher
- Diagnostic Medical Ultrasound Program, University of Missouri, Columbia, MO, USA
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18
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Enyuma COA, Adam A, Aigbodion SJ, McDowall J, Gerber L, Buchanan S, Laher AE. Role of the ultrasonographic ‘whirlpool sign’ in intestinal volvulus: a systematic review and meta-analysis. ANZ J Surg 2018; 88:1108-1116. [DOI: 10.1111/ans.14495] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 02/25/2018] [Accepted: 02/27/2018] [Indexed: 02/01/2023]
Affiliation(s)
- Callistus O. A. Enyuma
- Department of Emergency Medicine, Faculty of Health Sciences; University of the Witwatersrand; Johannesburg South Africa
- Department of Paediatrics, Faculty of Medicine; University of Calabar/Teaching Hospital; Calabar Nigeria
| | - Ahmed Adam
- Division of Urology, Faculty of Health Sciences; University of the Witwatersrand; Johannesburg South Africa
| | - Sunday J. Aigbodion
- Department of Emergency Medicine, Faculty of Health Sciences; University of the Witwatersrand; Johannesburg South Africa
| | - Jared McDowall
- Department of Emergency Medicine, Faculty of Health Sciences; University of the Witwatersrand; Johannesburg South Africa
| | - Louis Gerber
- Department of Emergency Medicine, Faculty of Health Sciences; University of the Witwatersrand; Johannesburg South Africa
| | - Sean Buchanan
- Department of Emergency Medicine, Faculty of Health Sciences; University of the Witwatersrand; Johannesburg South Africa
| | - Abdullah E. Laher
- Department of Emergency Medicine, Faculty of Health Sciences; University of the Witwatersrand; Johannesburg South Africa
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19
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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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20
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Grock A, Chan W, deSouza IS. A Curious Case of Right Upper Quadrant Abdominal Pain. West J Emerg Med 2016; 17:630-3. [PMID: 27625732 PMCID: PMC5017852 DOI: 10.5811/westjem.2016.7.31011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 07/07/2016] [Accepted: 07/19/2016] [Indexed: 11/11/2022] Open
Abstract
An otherwise healthy 36-year-old man presented with sudden-onset right upper quadrant abdominal pain and vomiting. A bedside ultrasound, performed to evaluate hepatobiliary pathology, revealed a normal gallbladder but free intraperitoneal fluid. After an expedited CT and emergent explorative laparotomy, the patient was diagnosed with a small bowel obstruction with ischemia secondary to midgut volvulus. Though midgut volvulus is rare in adults, delays in definitive diagnosis and management can result in bowel necrosis. Importantly, an emergency physician must be able to recognize bedside ultrasound findings associated with acutely dangerous intrabdominal pathology.
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Affiliation(s)
- Andrew Grock
- Olive View, UCLA Medical Center, Department of Emergency Medicine, Sylmar, California
- University of Southern California Medical Center and Keck School of Medicine, Department of Emergency Medicine, Los Angeles, California
| | - Wendy Chan
- SUNY Downstate Medical Center, Department of Emergency Medicine, Brooklyn, New York
- Kings County Hospital Department of Emergency Medicine, Brooklyn, New York
| | - Ian S. deSouza
- SUNY Downstate Medical Center, Department of Emergency Medicine, Brooklyn, New York
- Kings County Hospital Department of Emergency Medicine, Brooklyn, New York
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21
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Abstract
The small intestine is a complex organ system that is vital to the life of the individual. There are a number of congenital anomalies that occur and present most commonly in infancy; however, some may not present until adulthood. Most congenital anomalies of the small intestine will present with obstructive symptoms while some may present with vomiting, abdominal pain, and/or gastrointestinal bleeding. Various radiologic procedures can aid in the diagnosis of these lesions that vary depending on the particular anomaly. Definitive therapy for these congenial anomalies is surgical, and in some cases, surgery needs to be performed urgently. The overall prognosis of congenital anomalies of the small intestine is very good and has improved with improved medical management and the advent of newer surgical modalities. The congenital anomalies of the small intestine reviewed in this article include malrotation, Meckel's diverticulum, duodenal web, duodenal atresia, jejunoileal atresia, and duplications.
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Affiliation(s)
- Grant Morris
- Department of Pediatrics, Geisinger Clinic, 100 N. Academy Avenue, Danville, PA, 17822, USA
| | - Alfred Kennedy
- Department of Pediatric Surgery, Geisinger Clinic, 100 N. Academy Avenue, Danville, PA, 17822, USA
| | - William Cochran
- Department of Pediatric Gastroenterology, Geisinger Clinic, 100 N. Academy Avenue, Danville, PA, 17822, USA.
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22
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Diagnosis of pediatric gastric, small-bowel and colonic volvulus. Pediatr Radiol 2016; 46:130-8. [PMID: 26394623 DOI: 10.1007/s00247-015-3445-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Revised: 06/11/2015] [Accepted: 07/15/2015] [Indexed: 10/23/2022]
Abstract
Digestive volvulus affects the stomach, small bowel and mobile segments of the colon and often has a developmental cause. Reference radiologic examinations include upper gastrointestinal contrast series for gastric volvulus, possibly with ultrasonography for small-bowel volvulus, and contrast enema for colonic volvulus. Treatment is usually surgical. This pictorial essay describes the embryological development and discusses the clinical and radiologic presentation of volvulus, depending on location, and details the appropriate radiologic examinations.
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23
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Neonatal midgut volvulus: Spectrum of findings at color Doppler sonography. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2015. [DOI: 10.1016/j.ejrnm.2015.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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24
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Anticlockwise swirl: a potential pitfall for malrotation. J Pediatr Gastroenterol Nutr 2015; 60:e25. [PMID: 25714584 DOI: 10.1097/mpg.0000000000000644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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