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Kurian J, Winant AJ, Hull NC, Lee EY. Pediatric Acute Abdomen: Bread-and-Butter Diagnoses. Semin Roentgenol 2024; 59:312-331. [PMID: 38997184 DOI: 10.1053/j.ro.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 02/26/2024] [Indexed: 07/14/2024]
Affiliation(s)
- Jessica Kurian
- Department of Radiology, Westchester Medical Center, Valhalla, NY.
| | - Abbey J Winant
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | - Edward Y Lee
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, MA
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2
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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] [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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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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Rahmani P, Sharifi P, Ashjaee B, Ebrahimi M. Therapeutic actions in a 2-month-old child with teratoma and duodenal malrotation accompaniment. Ann Med Surg (Lond) 2022; 79:103952. [PMID: 35860118 PMCID: PMC9289314 DOI: 10.1016/j.amsu.2022.103952] [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: 04/04/2022] [Revised: 06/02/2022] [Accepted: 06/02/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction and importance: A mature mediastinal teratoma is a rare type of tumor that can contain fully developed tissues and it is usually considered benign, more common in female and may require surgical removal. The most common locations for teratomas are the tailbone (coccyx), ovaries, and testicles, but in this case, the teratoma was located in the mediastinum. Case presentation Furthermore, intestinal malrotation could potentially lead the patient to gastrointestinal (GI) obstruction and PO intolerance. Here, we present a 2-month-old patient with considerable manifestation of GI intolerance due to intestinal malrotaion accompanied by mature mediastinal teratoma. Clinical discussion An evaluation of malrotation should be part of every upper GI tract examination in pediatric patients, particularly newborns and infants. Conclusion Finally, in this case, surgical intervention could enhance both malrotation and mediastinal teratoma. A mature mediastinal teratoma is a rare type of tumor that can contain fully developed tissues. Benign, more common in female and may require surgical removal. Evaluation for malrotation should be part of every upper GI tract examination in pediatric patients. In this case, surgical intervention could enhance both malrotation and mediastinal teratoma. Finally, in this case, surgical intervention could enhance both malrotation and mediastinal teratoma.
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Affiliation(s)
- Parisa Rahmani
- Pediatric Gastroenterology and Hepatology Research Center, Children's Medical Center, Pediatric Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran
| | - Parastoo Sharifi
- Pediatric Gastroenterology and Hepatology Research Center, Children's Medical Center, Pediatric Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran
| | - Bahar Ashjaee
- Department of Pediatric Surgery, Pediatric Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Ebrahimi
- Pediatric Gastroenterology and Hepatology Research Center, Children's Medical Center, Pediatric Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran
- Corresponding author.
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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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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: 0] [Impact Index Per Article: 0] [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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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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Ligament of Treitz: Anatomy, Relevance of Radiologic Findings, and Radiologic-Pathologic Correlation. AJR Am J Roentgenol 2021; 216:927-934. [PMID: 33566632 DOI: 10.2214/ajr.20.23273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE. The objective of this article is to discuss the anatomy, embryonic origin, normal variants, and various attachments of the ligament of Treitz. We also describe the pathologic processes that develop along the ligament of Treitz and the role of cross-sectional imaging in identifying these conditions. CONCLUSION. The ligament of Treitz, also known as the suspensory ligament of the duodenum, is an important anatomic landmark in the abdomen. It is essential that radiologists understand the anatomic attachments, normal variants, and various pathologic conditions involving the ligament of Treitz as well as the role of cross-sectional imaging in the assessment of these conditions.
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Yassin S, Stoica I, Muntean A, Byrne A, Sweeney B. Chronic midgut volvulus - A challenging diagnosis. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2020. [DOI: 10.1016/j.epsc.2020.101676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Alazraki AL, Rigsby CK, Iyer RS, Bardo DME, Brown BP, Chan SS, Chandra T, Dietrich A, Falcone RA, Garber MD, Gill AE, Levin TL, Moore MM, Nguyen JC, Shet NS, Squires JH, Trout AT, Karmazyn B. ACR Appropriateness Criteria® Vomiting in Infants. J Am Coll Radiol 2020; 17:S505-S515. [PMID: 33153561 DOI: 10.1016/j.jacr.2020.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 09/01/2020] [Indexed: 10/23/2022]
Abstract
Vomiting in infants under the age of 3 months is one of the most common reasons for parents to seek care from their doctor or present to an emergency room. The imaging workup that ensues is dependent on several factors: age at onset, days versus weeks after birth, quality of emesis, bilious or nonbilious vomiting, and the initial findings on plain radiograph, suspected proximal versus distal bowel obstruction. The purpose of these guidelines is to inform the clinician, based on current evidence, what is the next highest yield and most appropriate imaging study to pursue a diagnosis. The goal is rapid and accurate arrival at a plan for treatment, whether surgical or nonsurgical. The following modalities are discussed for each variant of the symptom: plain radiography, fluoroscopic upper gastrointestinal series, fluoroscopic contrast enema, ultrasound of the abdomen, nuclear medicine gastroesophageal reflux scan. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Adina L Alazraki
- Children's Healthcare of Atlanta and Emory University, Atlanta, Georgia.
| | - Cynthia K Rigsby
- Panel Chair, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Ramesh S Iyer
- Panel Vice-Chair, Seattle Children's Hospital, Seattle, Washington
| | | | - Brandon P Brown
- Riley Hospital for Children Indiana University, Indianapolis, Indiana
| | | | | | - Ann Dietrich
- Nationwide Children's Hospital, Columbus, Ohio; American College of Emergency Physicians
| | - Richard A Falcone
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; American Pediatric Surgical Association
| | - Matthew D Garber
- University of Florida College of Medicine Jacksonville, Jacksonville, Florida; American Academy of Pediatrics
| | - Anne E Gill
- Children's Healthcare of Atlanta and Emory University, Atlanta, Georgia
| | - Terry L Levin
- The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Michael M Moore
- Penn State Health Children's Hospital, Hershey, Pennsylvania
| | - Jie C Nguyen
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Narendra S Shet
- Children's National Health System, Washington, District of Columbia
| | - Judy H Squires
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Andrew T Trout
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Boaz Karmazyn
- Specialty Chair, Riley Hospital for Children Indiana University, Indianapolis, Indiana
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Lv X, Chen H, Sun X, Zhou L, Lu C, Li H. Assessment of plasma microRNAs in congenital intestinal malrotation. Mol Med Rep 2020; 22:3289-3298. [PMID: 32945457 PMCID: PMC7453532 DOI: 10.3892/mmr.2020.11395] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 07/20/2020] [Indexed: 12/15/2022] Open
Abstract
Intestinal malrotation in newborns often requires urgent surgical treatment, especially in the presence of volvulus. Therefore, early-stage diagnosis is critical. In the present study, differentially expressed plasma microRNAs (miRNAs) were screened for in patients with intestinal malrotation using high-throughput Illumina sequencing, and validated using reverse transcription-quantitative PCR. Receiver operating characteristic curve (ROC) analysis was conducted to evaluate their specificity, sensitivity and assess their diagnostic value for intestinal malrotation. Bioinformatics analysis was performed to investigate the functions associated with the dysregulated miRNAs. A profile consisting of 28 differentially expressed plasma miRNAs was obtained, of which nine were verified to exhibit significantly altered expression. According to a ROC analysis, four of these could represent novel early-stage, non-invasive biomarkers for intestinal malrotation. Bioinformatics analysis demonstrated that the differentially expressed miRNAs were predominantly involved in ‘metal ion transmembrane transporter activity’ and ‘calcium-dependent protein binding’, which may be related to the ‘endocytosis’ pathway. In conclusion, significantly differentially expressed plasma miRNAs were identified in congenital intestinal malrotation and their potential roles were described. These differentially expressed miRNAs may serve as biomarkers of intestinal malrotation and improve early diagnosis for this condition.
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Affiliation(s)
- Xiurui Lv
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, Jiangsu 210008, P.R. China
| | - Huan Chen
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, Jiangsu 210008, P.R. China
| | - Xinhe Sun
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, Jiangsu 210008, P.R. China
| | - Lingling Zhou
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, Jiangsu 210008, P.R. China
| | - Changgui Lu
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, Jiangsu 210008, P.R. China
| | - Hongxing Li
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, Jiangsu 210008, P.R. China
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Visceral variations in adult intestinal malrotation: A case-series study. JOURNAL OF SURGERY AND MEDICINE 2020. [DOI: 10.28982/josam.762738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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15
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Cho HH, Lee SM, You SK. Gastrointestinal Emergencies in Neonates: What We Should Know. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2020; 81:770-793. [PMID: 36238170 PMCID: PMC9432200 DOI: 10.3348/jksr.2020.81.4.770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/14/2020] [Accepted: 05/23/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Hyun-Hae Cho
- Department of Radiology, Ewha Womans University Mokdong Hospital, Seoul, Korea
| | - So Mi Lee
- Department of Radiology, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Korea
| | - Sun Kyoung You
- Department of Radiology, Chungnam National University School of Medicine, Chungnam National University Hospital, Daejeon, Korea
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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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A Multi-institutional Case Series With Review of Point-of-Care Ultrasound to Diagnose Malrotation and Midgut Volvulus in the Pediatric Emergency Department. Pediatr Emerg Care 2019; 35:443-447. [PMID: 30702647 DOI: 10.1097/pec.0000000000001737] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Point-of-care ultrasound can be used to screen for malrotation with and without volvulus in the newborn with bilious vomiting, as well as children with unexplained intermittent abdominal pain. We discuss cases where infants and children presenting to pediatric emergency departments with bilious vomiting and/or intermittent abdominal pain were initially screened for small bowel pathology with point-of-care ultrasound. Bedside findings suggestive of midgut volvulus were confirmed with radiology-performed ultrasound or upper gastrointestinal fluoroscopy. In all cases, operative findings were consistent with malrotation of the small bowel with or without evidence of midgut volvulus.
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Duodenum Inversum: A Rare Cause of Chronic Nausea and Vomiting. Case Rep Gastrointest Med 2018; 2018:7538601. [PMID: 30675403 PMCID: PMC6323429 DOI: 10.1155/2018/7538601] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/25/2018] [Accepted: 12/05/2018] [Indexed: 12/05/2022] Open
Abstract
Duodenum inversum (DI), also known as inverted duodenum or duodenum reflexum, is a congenital malformation in which the third portion of the duodenum, instead of continuing leftward to the ligament of Treitz, reverses direction and travels in a superior, posterior track prior to crossing the midline above the pancreas. We present a case of a 62-year-old woman presenting with chronic nausea and vomiting, subsequently found to have DI.
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Mimics of malrotation on pediatric upper gastrointestinal series: a pictorial review. Abdom Radiol (NY) 2018; 43:2246-2254. [PMID: 29500650 DOI: 10.1007/s00261-018-1537-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Intestinal malrotation is a continuum of congenital anomalies due to lack of rotation or incomplete rotation of the fetal intestine around the superior mesenteric artery axis. The abnormal bowel fixation (by mesenteric bands) or absence of fixation of portions of the bowel increases the risk of bowel obstruction, acute or chronic volvulus, and bowel necrosis. The clinical presentation of patients with malrotation without, with intermittent, or with chronic volvulus can be problematic, with an important minority presenting late or having atypical or chronic symptoms, such as intermittent vomiting, abdominal pain, duodenal obstruction, or failure to thrive. The diagnosis is heavily reliant on imaging. Upper GI series remain the gold standard with the normal position of the duodenojejunal junction lateral to the left-sided pedicles of the vertebral body, at the level of the duodenal bulb on frontal views and posterior (retroperitoneal) on lateral views. However, a variety of conditions might influence the position of the duodenojejunal junction, potentially leading to a misdiagnosis of malrotation. Such conditions include improper technique, gastric over distension, splenomegaly, renal or retroperitoneal tumors, liver transplant, small bowel obstruction, the presence of properly or malpositioned enteric tubes, and scoliosis. All of these may cause the duodenojejunal junction to be displaced. We present a series of cases highlighting conditions that mimic malrotation without volvulus to increase the practicing radiologist awareness and help minimize interpretation errors.
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Judit Machnitz A, Reid JR, Acord MR, Khwaja AB, Biko DM, Ayyala RS, Anupindi SA. MRI of the bowel - beyond inflammatory bowel disease. Pediatr Radiol 2018; 48:1280-1290. [PMID: 30078046 DOI: 10.1007/s00247-018-4166-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 04/20/2018] [Accepted: 05/22/2018] [Indexed: 02/06/2023]
Abstract
MR enterography is traditionally used to evaluate inflammatory bowel disease (IBD) both at initial presentation and at follow-up. MR enterography can also be used to evaluate non-IBD conditions such as polyps or other masses of the gastrointestinal tract. In this article, we emphasize how to recognize bowel conditions beyond IBD on conventional abdominal MRI without a specific enterographic technique. In this overview we discuss common and uncommon pediatric bowel conditions beyond IBD seen on MRI including infectious and inflammatory conditions, congenital diseases and tumor and tumor-like conditions. Radiologists should become familiar with the salient imaging features of these bowel conditions to help guide management.
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Affiliation(s)
- A Judit Machnitz
- Department of Radiology, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Janet R Reid
- Department of Radiology, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Michael R Acord
- Department of Radiology, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Asef B Khwaja
- Department of Radiology, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - David M Biko
- Department of Radiology, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Rama S Ayyala
- Department of Radiology, Morgan Stanley Children's Hospital, New York Presbyterian, Columbia School of Medicine, New York, NY, USA.,Department of Diagnostic Imaging, Rhode Island Hospital - Hasbro Children's Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Sudha A Anupindi
- Department of Radiology, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA.
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Ismail M, Elgffar Helal AA. Laparoscopic diagnostic finding in atypical intestinal malrotation in children with equivocal imaging studies. Afr J Paediatr Surg 2018; 15:121-125. [PMID: 32769361 PMCID: PMC7646688 DOI: 10.4103/ajps.ajps_132_13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Atypical presentation of intestinal malrotation provide a diagnostic and therapeutic dilemma for the surgeon to answer the question is it wisdom to operate or not? Upper gastrointestinal (UGI) contrast study is essential for diagnosis; however, 'soft' radiologic findings place the responsibility of excluding malrotation directly on the surgeon. Recently, minimally invasive surgical techniques would be able to accomplish the identical evaluation and treatment of this group of patients. PATIENTS AND METHODS A total of 40 patients (25 male, 15 female), age of 2-14 years, presented with symptoms of chronic abdominal pain, intermittent upper intestinal obstruction, recurrent bilious vomiting and failure to thrive. On clinical examination, none of the patients had signs of acute abdominal emergency. UGI contrast study was done and it was equivocal. All patients underwent laparoscopic evaluation. RESULTS A total of 36 patients (90%) were found on laparoscopy to have a discrepant finding of chronic intestinal malrotation. With narrow mesenteric base which put them at significant risk of midgut volvulus. Two patients (5%) were found to have chronic appendicitis with extensive adhesion at the right iliac fossa, one patient (2.5%) has annular pancreas and one patient has negative laparoscopic exploration. Laparoscopic findings of chronic intestinal malrotation includes, huge dilated stomach and the first part of duodenum, ectopic site of caecum central in the abdomen or under the liver, medial and low position of duodenojejunal junction, congested mesenteric veins with lymphatic oedema, generalised mesenteric lymphadenopathy, reversed relation of superior mesenteric artery and vein, right-sided small bowel. CONCLUSION Laparoscopic diagnostic finding permits direct evaluation and treatment of undocumented malrotation in children, with equivocal UGI contrast study. Furthermore, laparoscopy provides an excellent opportunity to assess the base of the mesentery. Those children with a narrow base should undergo laparoscopic Ladd procedure to avoid catastrophic midgut volvulus.
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Affiliation(s)
- Maged Ismail
- Pediatric Surgery Unit, Al-Azhar University Hospitals, Cairo, Egypt
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22
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Diagnostic Value of Ultrasound and Gastrointestinal Series Findings in Detection of Pediatric Intestinal Malrotation. IRANIAN JOURNAL OF RADIOLOGY 2018. [DOI: 10.5812/iranjradiol.15089] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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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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Abstract
Intestinal rotation abnormality (IRA) predisposes to lethal midgut volvulus. An understanding of intestinal development illustrates the process of normal intestinal rotation and fixation. An appreciation of the clinical presentation and consequences of missed IRA will enhance clinical suspicion and timely evaluation. Selecting the appropriate imaging modality to diagnose IRA requires an understanding of the benefits and limitations of each. The Ladd's procedure continues to be the appropriate surgical treatment for IRA with or without volvulus. Laparoscopy has emerged as an option for the diagnosis and treatment of IRA. Populations in which IRA is always associated, but a Ladd's procedure rarely required, include patients with congenital diaphragmatic hernia and abdominal wall defects. Prevalence of IRA is higher in children with congenital heart disease and heterotaxy syndrome; asymptomatic patients require multidisciplinary consideration of the risks and benefits of screening for IRA, whether a Ladd's procedure is required, and the timing thereof. [Pediatr Ann. 2016;45(7):e247-e250.].
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Medical Management of Duodenum Inversum Presenting With Partial Proximal Intestinal Obstruction in a Pediatric Patient. J Pediatr Gastroenterol Nutr 2016; 62:e64-5. [PMID: 25079483 PMCID: PMC4312261 DOI: 10.1097/mpg.0000000000000519] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Duodenum inversum is a rare congenital anomaly of unknown etiology whereby the duodenum travels superiorly to the level of the duodenal bulb and then posteriorly prior to crossing the midline above the pancreas. We describe the first pediatric case of duodenum inversum presenting as partial proximal intestinal obstruction that was medically managed without surgical intervention.
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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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Raske ME, Dempsey ME, Dillman JR, Dory CE, Garber M, Hayes LL, Iyer RS, Kulkarni AV, Myseros JS, Rice HE, Rigsby CK, Ryan ME, Strouse PJ, Westra SJ, Wootton-Gorges SL, Coley BD, Karmazyn B. ACR Appropriateness Criteria Vomiting in Infants up to 3 Months of Age. J Am Coll Radiol 2015; 12:915-22. [DOI: 10.1016/j.jacr.2015.05.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 05/24/2015] [Indexed: 11/28/2022]
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28
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Laparoscopic diagnostic findings in atypical intestinal malrotation in children with equivocal imaging studies. ANNALS OF PEDIATRIC SURGERY 2015. [DOI: 10.1097/01.xps.0000469157.12636.6f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Miyano G, Fukuzawa H, Morita K, Kaneshiro M, Miyake H, Nouso H, Yamoto M, Fukumoto K, Urushihara N. Laparoscopic Repair of Malrotation: What Are the Indications in Neonates and Children? J Laparoendosc Adv Surg Tech A 2015; 25:155-8. [DOI: 10.1089/lap.2014.0236] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Go Miyano
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Hiroaki Fukuzawa
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Keiichi Morita
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Masakatsu Kaneshiro
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Hiromu Miyake
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Hiroshi Nouso
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Masaya Yamoto
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Koji Fukumoto
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Naoto Urushihara
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
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Malrotación-vólvulo intestinal: hallazgos radiológicos. RADIOLOGIA 2015; 57:9-21. [DOI: 10.1016/j.rx.2014.07.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 07/13/2014] [Accepted: 07/21/2014] [Indexed: 11/21/2022]
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Nayak GK, Levin TL, Kurian J, Kohli A, Borenstein SH, Goldman HS. Bedside upper gastrointestinal series in critically ill low birth weight infants. Pediatr Radiol 2014; 44:1252-7. [PMID: 24805204 DOI: 10.1007/s00247-014-2993-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 12/27/2013] [Accepted: 03/30/2014] [Indexed: 12/23/2022]
Abstract
BACKGROUND The upper gastrointestinal (UGI) series is the preferred method for the diagnosis of malrotation. A bedside UGI technique was developed at our institution for use in low birth weight, critically ill neonates to minimize the risks of transportation from the neonatal intensive care unit (NICU) such as hypothermia and dislodgement of support lines and tubes. OBJECTIVE To determine the ability of a bedside UGI technique to identify the position of the duodenojejunal junction (DJJ) in low birth weight, critically ill infants in the NICU. MATERIALS AND METHODS We retrospectively reviewed bedside UGI examinations performed in premature infants weighing less than 1,500 g from 2008 to 2013 and correlated the findings with clinical data, imaging studies and surgical findings. RESULTS Of 27 patients identified (weight range: 633-1,495 g), 21 (78%) bedside UGI series were diagnostic. Twenty of 27 cases (74%) demonstrated normal intestinal rotation. One case demonstrated malrotation with midgut volvulus, which was confirmed at surgery. In six cases (22%), the position of the DJJ could not be accurately determined. No cases of malrotation with midgut volvulus were missed. None of the patients with normal bedside UGI studies was found to have malrotation based on clinical follow-up (mean: 20 months), surgical findings or further imaging. CONCLUSION The bedside UGI is a useful technique to exclude malrotation in critically ill neonates and minimizes potential risks of transportation to the radiology suite. Pitfalls that may preclude a diagnostic examination include incorrect timing of radiographs, patient rotation, suboptimal enteric tube position and bowel distention. In cases of diagnostic uncertainty, a follow-up study should be performed.
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Affiliation(s)
- Gopi K Nayak
- Department of Radiology, Division of Pediatric Radiology, Montefiore Medical Center, 111 East 210 St., Bronx, NY, 10467, USA
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Khatami A, Mahdavi K, Karimi MA. Ultrasound as a feasible method for the assessment of malrotation. Pol J Radiol 2014; 79:112-6. [PMID: 24860630 PMCID: PMC4031226 DOI: 10.12659/pjr.890219] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 01/13/2014] [Indexed: 11/21/2022] Open
Abstract
Background In malrotation the position of third portion of duodenum (D3) is always intramesenteric. Demonstration of normal retromesenteric-retroperitoneal position of D3 on ultrasound (US) can rule out malrotation. The aim of this study was to evaluate the feasibility of US in demonstrating the retroperitoneal D3. Material/Methods Abdominal US study was done for various indications in 60 newborns and infants (mean age: 33 days [range: 4–100 days]; 56.7% male) by an expert pediatric radiologist. The position of D3 and its adjacent structures was evaluated in axial and longitudinal planes by linear and curved transducers. Results A normal retromesenteric-retroperitoneal D3 located between the superior mesenteric artery and the aorta was seen on US in all patients, including those with extensive gas in the bowel. The mean time of D3 observation was 47.8 s (10–180 s). Ultrasound was also capable of demonstrating D3 structure, diameter, content, adjacent structures, relative position of the superior mesenteric artery and vein. Conclusions Ultrasound is a simple, fast and highly accurate tool to confirm the retroperitoneal position of D3. Ultrasound can be used as a screening method for malrotation eliminating the need for unnecessary barium studies.
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Affiliation(s)
- Alireza Khatami
- Department of Radiology, Mofid Children's Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Kiarash Mahdavi
- Department of Radiology, Mofid Children's Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Ali Karimi
- Department of Radiology, Mofid Children's Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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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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Disorders of midgut rotation: making the correct diagnosis on UGI series in difficult cases. Pediatr Radiol 2013; 43:1093-102. [PMID: 23588775 DOI: 10.1007/s00247-013-2676-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Revised: 01/21/2013] [Accepted: 01/30/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND In some series of malrotation small numbers of children are described in whom the position of the duodenojejunal flexure was considered to be normal on straight anteroposterior (AP) view of an upper gastrointestinal (UGI) series. OBJECTIVE The purpose of this study was to illustrate children with disorders of midgut rotation in whom the diagnosis was difficult because on the straight AP view of the UGI series the duodenojejunal flexure was either not clearly depicted or was projected to the left of the midline close to its expected normal position at or close to the level of the duodenal cap. MATERIALS AND METHODS We reviewed 111 children with malrotation to determine the frequency that duodenojejunal flexure was not clearly depicted or was close to normal position. RESULTS Seven patients had close to normal position of duodenojejunal flexure on AP view. The correct diagnosis was made on initial UGI series in four patients based on other features on AP and lateral views. In two of the other three patients, a repeat UGI series facilitated the correct diagnosis. In the final patient, an abnormal position of a nasojejunal tube suggested the correct diagnosis. CONCLUSION Accurate diagnosis of anomalies of midgut rotation requires careful assessment of the entire duodenal sweep on both AP and lateral views to avoid false-negative interpretations.
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Taslakian B, Issa G, Hourani R, Akel S. Left-sided appendicitis in children with congenital gastrointestinal malrotation: a diagnostic pitfall in the emergency department. BMJ Case Rep 2013; 2013:bcr-2013-009474. [PMID: 23761499 DOI: 10.1136/bcr-2013-009474] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Acute appendicitis is one of the most common conditions requiring emergency surgery. However, acute appendicitis presenting with left lower quadrant abdominal pain is extremely rare. Imaging, particularly CT , plays an important role in establishing an accurate and prompt diagnosis, as delay in diagnosis may occur due to lack of uniformity in the clinical signs and symptoms. We report a rare case of a 10-year-old boy who presented with persistent left lower quadrant pain of several days duration, in which the CT scan of the abdomen and pelvis was essential in establishing the correct diagnosis. The malpositioned inflamed appendix was clearly identified in the left side of the abdomen, with the characteristic CT findings of uncomplicated intestinal malrotation. Left-sided acute appendicitis should be considered in the differential diagnosis of young patients presenting with left lower quadrant pain, in order to avoid delay in diagnosis and guide the surgical intervention.
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Affiliation(s)
- Bedros Taslakian
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Beirut, Lebanon
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A pattern-based approach to bowel obstruction in the newborn. Pediatr Radiol 2013; 43:318-29. [PMID: 23233046 DOI: 10.1007/s00247-012-2573-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2012] [Revised: 10/21/2012] [Accepted: 10/29/2012] [Indexed: 12/20/2022]
Abstract
Intestinal obstruction is common in newborns, and the radiologist plays a critical role in the care of these children. Diagnosing and managing the potentially obstructed newborn can be challenging, especially given the myriad underlying pathologies that range from benign to acutely life-threatening. A familiarity with the most common diagnoses is essential, but equally important to the radiologist is a systematic approach to management of the child in this setting. We propose an approach based on the recognition of eight radiographic patterns, five upper gastrointestinal examination (UGI) patterns and four contrast enema patterns. Recognition of these patterns directs further imaging when necessary and allows triage of children who can be managed medically, those requiring elective or urgent surgery and those requiring emergent surgery.
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Kim ME, Fallon SC, Bisset GS, Mazziotti MV, Brandt ML. Duodenum inversum: a report and review of the literature. J Pediatr Surg 2013; 48:e47-9. [PMID: 23331840 DOI: 10.1016/j.jpedsurg.2012.10.066] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Revised: 10/30/2012] [Accepted: 10/31/2012] [Indexed: 11/19/2022]
Abstract
Duodenum inversum is a rare congenital malformation defined by a duodenum which travels superiorly and then posteriorly prior to crossing the midline above the pancreas. It is often confused with other, more common, anomalies of intestinal rotation. We present a case of duodenum inversum diagnosed incidentally in a one-month old infant with Trisomy 21 during evaluation for reflux disease. Due to an inability to definitively rule out malrotation, the diagnosis was confirmed with a diagnostic laparoscopy. We discuss available literature concerning this rare anatomic anomaly as well as provide recommendations for diagnosis and treatment.
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Affiliation(s)
- Michael E Kim
- Division of Pediatric Surgery, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA
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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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Value of laparoscopy in children with a suspected rotation abnormality on imaging. J Pediatr Surg 2011; 46:1347-52. [PMID: 21763833 DOI: 10.1016/j.jpedsurg.2010.12.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2010] [Revised: 12/08/2010] [Accepted: 12/10/2010] [Indexed: 11/22/2022]
Abstract
BACKGROUND Although imaging is usually used for the diagnosis of rotation abnormalities, significant false-positive and false-negative rates have been reported. We studied the utility of laparoscopy in the management of children with a suspected rotation abnormality on imaging. METHODS The charts of all children undergoing laparoscopy for a suspected intestinal rotation abnormality from January 2000 to August 2009 were retrospectively reviewed. RESULTS There were 51 patients. Preoperative diagnosis based on upper gastrointestinal contrast study with or without contrast enema or ultrasound was malrotation without volvulus in 47%, malrotation with volvulus in 10%, and nonrotation in 6%; the other 37% had equivocal or inconclusive imaging studies. Of the patients who had a "definitive" preoperative diagnosis, 41% had a discrepant finding at laparoscopy. For those with inconclusive imaging studies, 32% were found on laparoscopy to have a narrow mesenteric base, which put them at significant risk of midgut volvulus. CONCLUSION Imaging studies may be inaccurate in differentiating malrotation from nonrotation or normal rotation. Laparoscopy provides an excellent opportunity to assess the base of the mesentery. Those children without a narrow-based mesentery can undergo laparoscopy alone, and those with malrotation should undergo either laparoscopic or open Ladd procedure.
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US as a primary tool in the work-up of malrotation. Pediatr Radiol 2010; 40:1844-5; author reply 1846-7. [PMID: 20686760 DOI: 10.1007/s00247-010-1795-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2010] [Accepted: 07/21/2010] [Indexed: 10/19/2022]
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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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Pediatrics. Emerg Radiol 2009. [DOI: 10.1017/cbo9780511691935.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Other emergencies. Emerg Radiol 2009. [DOI: 10.1017/cbo9780511691935.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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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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Ferdman B, States L, Gaynor JW, Hedrick HL, Rychik J. Abnormalities of intestinal rotation in patients with congenital heart disease and the heterotaxy syndrome. CONGENIT HEART DIS 2008; 2:12-8. [PMID: 18377511 DOI: 10.1111/j.1747-0803.2007.00066.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Abnormalities of intestinal rotation (AIR) are seen in association with congenital heart disease and heterotaxy syndrome. The prevalence of these abnormalities and recommendations for management are unclear. Our objective was to determine the prevalence of screening for AIR by elective imaging among our group and prophylactic vs. emergent surgical intervention for AIR in patients with congenital heart disease and heterotaxy syndrome. METHODS From October 1988 through October 2000, we identified 74 patients with congenital heart disease and heterotaxy syndrome, 44 (59%) asplenia, 30 (41%) polysplenia. Abdominal imaging was performed in 34 patients (45%). Twenty-four (32%) were found to have AIR. Of 34 patients imaged, 22 (65%) were found to have AIR. Two patients not imaged were found to have AIR: one at autopsy, and the other, incidentally during other abdominal surgery. Because imaging was performed based on individual cardiologist's practice style that did not change over the period of the study and rarely secondary to symptoms, it is likely that the prevalence of AIR in the patients that were not electively imaged would be similar. RESULTS There was no statistical difference in the presence of AIR between asplenic (34%[15/44]) and polysplenic (30%[9/30]) patients. Of the 22 patients imaged with AIR, 18 underwent Ladd procedure. Five of 12 imaged patients without AIR were found to have other significant gastrointestinal pathologies requiring intervention including gastrostomy tube placement for reflux (3), duodenal web (1), and biliary atresia (1). Of the 40 patients who were not pre-emptively imaged, none suffered acute obstruction solely secondary to AIR. However, in 2 patients intestinal obstruction was suspected and subsequently discovered by imaging and/or laparotomy due to other intestinal anomalies. CONCLUSIONS AIR is common among patients with heterotaxy syndrome and congenital heart disease. We recommend that patients with congenital heart disease and heterotaxy syndrome have routine elective abdominal imaging of their gastrointestinal tract at birth as part of their evaluation.
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Affiliation(s)
- Barbara Ferdman
- Washington University School of Medicine-Pediatrics, St Louis, MO, USA
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Sizemore AW, Rabbani KZ, Ladd A, Applegate KE. Diagnostic performance of the upper gastrointestinal series in the evaluation of children with clinically suspected malrotation. Pediatr Radiol 2008; 38:518-28. [PMID: 18265969 DOI: 10.1007/s00247-008-0762-8] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2007] [Revised: 12/14/2007] [Accepted: 01/08/2008] [Indexed: 12/30/2022]
Abstract
BACKGROUND Malrotation is a congenital disorder of abnormal intestinal rotation and fixation that predisposes infants to potentially life-threatening midgut volvulus. Upper gastrointestinal tract (UGI) examination is sometimes equivocal and can lead to inaccurate diagnosis. OBJECTIVE To determine the diagnostic performance of UGI examinations in children who subsequently underwent a Ladd procedure for suspected malrotation or volvulus. MATERIALS AND METHODS We reviewed all children up to 21 years old who had undergone both a UGI examination and a Ladd procedure for possible malrotation across 9 years. Children were excluded if they had not undergone either a UGI examination or a Ladd procedure and if congenital abdominal wall defects were present. RESULTS Of 229 patients identified, 166 (59% male, median age 67 days) were included. Excluded were 47 without a UGI series, 12 with omphalocele or gastroschisis, 1 without verifiable operative data, 1 who had not undergone a Ladd procedure, and 2 older than 21 years. Of the 166 patients, 40% were neonates and 73% were <12 months old, and 31% presented with bilious vomiting and 15% with abdominal distention. Of 163 patients with surgically verified malrotation, 156 had a positive UGI examination, a sensitivity of 96%. There were two patients with a false-positive UGI examination and seven with false-negative examination. Jejunal position was normal in six of the seven with a false-negative examination and abnormal in the two with a false-positive examination. Of 38 patients with surgically verified volvulus, 30 showed volvulus on the UGI series. Five required bowel resection and three died. CONCLUSION Jejunal position can lead to inaccurate UGI series interpretation. Meticulous technique and periodic assessment of performance will help more accurately diagnose difficult or equivocal cases.
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Affiliation(s)
- Alecia W Sizemore
- Department of Radiology, Indiana University School of Medicine, Indianapolis, IN, USA
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