Clockwise whirlpool sign at color Doppler US: an objective and definite sign of midgut volvulus

Impact of Focused Abdominal Ultrasound Utilization on Outcomes for Children With Midgut Volvulus

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.

The role of multimodal ultrasound in diagnosis of fetal bowel dilatation and prediction of adverse neonatal outcomes: A study of 86 cases in a series of 43,562 births

Objective

To investigate the diagnostic utility of multimodal ultrasound for fetal bowel dilatation (FBD) in different parts of the bowel and to examine its prognostic potential in FBD.

Methods

This retrospective study analyzed 86 fetuses with a dilated bowel identified via ultrasound in a 10-month postnatal follow-up. Both two- and three dimensional (2D and 3D, respectively) ultrasound volume imaging were used to characterize dilation across different bowel sections. The optimal intestinal diameter cut-off values for pathological bowel dilatation were determined and a predictive model for neonatal surgery was developed.

Results

The 86 cases of dilatation were distributed as follows: duodenal (n = 36); jejunum/ileum (n = 35); and colonic (n = 15). Duodenal dilatations presented the earliest during pregnancy compared to the other 2 groups (24.4 versus [vs.] 29 vs. 33.7 weeks respectively; p < 0.05). Cases with small intestinal dilatation were delivered earlier than those with colonic dilatation (p < 0.05). Infants with duodenal dilatation had the lowest birth weight and the highest rate of multi-system abnormalities (30.6% vs. 5.7% vs. 20%; p < 0.001). More than one-half of the multi-system abnormalities had chromosomal abnormalities (multiple, 54% vs. single, 12.5%; p = 0.015). There were 2 stillbirths, 24 induced labors, 44 postnatal surgeries, and 18 normal cases after birth. In predicting adverse neonatal outcomes of jejunum/ileum dilatation using a cut-off value of 15.5 mm small intestine diameter, sensitivity was 81.5%, specificity was 62.5%, and the area under the receiver operating characteristic curve (AUC) was 0.762 (p < 0.05). For colonic dilatation, using a cut-off value of 21.5 mm colon diameter: sensitivity was 83.3%, specificity was 77.8%, and AUC was 0.861 (p < 0.05). In detecting jejunum/ileum and colonic obstruction, 3D ultrasound demonstrated significantly better diagnostic efficiency than 2D ultrasound (p < 0.05). Using the backward stepwise selection method, a predictive model for neonatal surgery in patients with jejunum/ileum and colonic dilatation was established: logit (P) = -1.58 + (2.32 × polyhydramnios) +(2.0 × ascites) +(1.14 × hyperechogenic bowel). The AUC for the prediction model was 0.874 (p < 0.05), with 76% sensitivity and 94.1% specificity.

Conclusions

Duodenal dilatation occurred earlier, with a higher incidence of chromosomal abnormalities and multi-system abnormalities than dilatation of other parts of the bowel. 3D ultrasound played an important role in the detection of jejunum/ileum and colon obstructions. Clinical signs, including polyhydramnios, ascites, and strong echoes in the intestine, can be used to predict neonatal surgery.

Ultrasonic Diagnosis of Intestinal Obstruction in Neonates-Original Article

BACKGROUND

Intestinal obstruction in neonates is a common problem that requires prompt diagnosis and treatment, and ultrasound could be a potential tool for it. The purpose of this study was to investigate the accuracy of ultrasonography in diagnosing and identifying the cause of intestinal obstruction in neonates, the corresponding ultrasonic manifestations, as well as to utilize the diagnostic method.

METHODS

We conducted a retrospective study of all neonatal intestinal obstruction in our institute between 2009 and 2022. The accuracy of ultrasonography in the diagnosis of intestinal obstruction and the identification of its etiology was compared with the results of operation as the gold standard.

RESULTS

The accuracy of the ultrasonic diagnosis of intestinal obstruction was 91%, and the accuracy of the ultrasonic etiological diagnosis of intestinal obstruction was 84%. The main ultrasound findings for the neonatal intestinal obstruction were dilation and high tension of the proximal bowel and collapse of the distal intestinal. Other major manifestations were the presence of corresponding diseases causing intestinal obstruction at the junction of the dilated and collapsed bowel.

CONCLUSIONS

Ultrasound has the advantages of being a flexible multi-section dynamic evaluation and a valuable tool to diagnose and identify the cause of intestinal obstruction in neonates.

US for Evaluation of Acute Abdominal Conditions in Neonates

US is the imaging modality of choice for evaluation of a variety of abdominal conditions, and in recent years it has also become useful and promising as a bedside technique for assessment of acute abdominal conditions in neonates. Bedside US can help, complement, and sometimes replace radiographic or contrast-enhanced studies in critically ill and labile neonates who are difficult to transport to the fluoroscopy suite. Some of the features of bedside US can be applied as point-of-care US (POCUS) of the sick neonate. Some of the abdominal conditions in neonates that can be assessed and monitored with bedside US are necrotizing enterocolitis and its complications, malrotation with a midgut volvulus, segmental volvulus, meconium peritonitis, and complicated inguinal hernia. High-resolution US with the use of 15-MHz and higher-frequency probes allows characterization of the bowel anatomy and features of intestinal abnormalities in neonates in fine detail. Color Doppler US and microvascular imaging improve accuracy in the detection and characterization of bowel vascularity, which is important in the treatment and follow-up of patients with intestinal conditions. ^© RSNA, 2023 Quiz questions for this article are available through the Online Learning Center. The slide presentation from the RSNA Annual Meeting is available for this article.

Bleeding per rectum in pediatric population: A pictorial review

Bleeding per rectum in children can be seen in congenital as well as acquired conditions that may require medical or surgical management. The present review article is aimed to discuss the imaging findings of some common and uncommon causes of bleeding per rectum in children.

Bleeding per rectum in pediatric population: A pictorial review

Bleeding per rectum in children can be seen in congenital as well as acquired conditions that may require medical or surgical management. The present review article is aimed to discuss the imaging findings of some common and uncommon causes of bleeding per rectum in children.

Ultrasound for malrotation and volvulus - point

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.

Ultrasound for Midgut Malrotation and Midgut Volvulus: AJR Expert Panel Narrative Review

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.

Jejunal volvulus within an inguinal hernia sac like as an extremely rare cause of acute mechanical gastrointestinal obstruction in adults: First literature report

INTRODUCTION AND IMPORTANCE

Small bowel volvulus (SBV) represents a rare and life-threatening cause of gastrointestinal obstruction among adults. SBV can be classified as primary and secondary subtypes. Preoperative diagnosis of SBV is a challenge because of the absence of pathognomonic clinical, radiographic and laboratory findings. Surgery represents the correct treatment of SBV.

CASE PRESENTATION

A 69-year-old Caucasian male presented to the Emergency Department with a two-day history of abdominal pain, inability to pass gas or stool, nausea, vomiting. Physical examination revealed abdominal distension, generalized abdominal pain without guarding or rebound tenderness, a partially reducible and painless right inguinal hernia. Laboratory tests reported neutrophilic leukocytosis. Abdominal computed tomography revealed massive gastroduodenal dilatation with pneumoperitoneum and small bowel loops in the right inguinal sac. The patient underwent exploratory laparotomy: a jejunal volvulus (JV) located within the right inguinal hernia sac, causing gastrointestinal obstruction, was devolvulated and a right prosthetic inguinal hernia repair was also performed. The patient was discharged on the 10th postoperative day.

CLINICAL DISCUSSION

Secondary SBV is due to any congenital or acquired lesions and rarely occurs among adults in Western countries. This is the first literature report of a JV located within an inguinal hernia sac causing gastrointestinal obstruction.

CONCLUSION

Secondary JV represents an extremely rare abdominal emergency necessitating early diagnosis to prevent the development of intestinal ischemia, bowel necrosis and peritonitis. Diagnosis of JV needs a high index of suspicion and may be facilitated by imaging, often it is made intraoperatively. Surgery represents the appropriate treatment of JV.

Target sign of intussusception versus whirlpool sign of midgut volvulus

We report the case of a 2-month-old boy who presented with emesis and was initially thought to have an intussusception based on ultrasound findings, but was later found to have malrotation with midgut volvulus. He was surgically detorsed before any bowel necrosis occurred, but later developed recurrent volvulus due to a surgical adhesion acting as an anchor point. The aim of this report is to highlight the imaging similarities and differences between intussusception and the more serious midgut volvulus in order to expedite proper care and preserve bowel. Malrotation with midgut volvulus is a pediatric surgical emergency involving twisting of a congenitally shortened mesentery around the superior mesenteric artery, leading to rapid vascular compromise and ischemic necrosis of small bowel. Prompt diagnosis is critical but difficult, as imaging findings in volvulus can appear similar to those in intussusception. Treatment with a Ladd procedure can safely and effectively reduce the volvulus and prevent recurrence.

Prenatal imaging features and perinatal outcomes of foetal volvulus-A literature review

OBJECTIVE

To conduct a review of the literature on foetal volvulus with emphasis on prenatal imaging, pregnancy characteristics and clinical outcomes.

METHODS

A review of all published cases of foetal volvulus diagnosed prenatally and indexed in Medline, EBSCOhost, CINAHL, SOCIndex and Healthy Policy Reference Centre. Studies without antenatal sonographic signs of foetal volvulus and without a postpartum surgical diagnosis were excluded. Data were analysed for frequencies and distributions and tested for statistical significance.

RESULTS

Eighty-eight cases of foetal volvulus were identified from 58 published case reports/series. The most common ultrasound findings were dilated bowel/stomach (77.3%), polyhydramnios (30.7%) and whirlpool/snail sign (28.4%). Median gestation at diagnosis was 31.9 weeks (IQR 27-34) and mean gestation at delivery was 34.5 weeks (SD 2.8). Underlying aetiology included intestinal malrotation (15.9%), cystic fibrosis (14.8% of all cases, 32.5% of tested cases) and abnormal mesenteric fixation (12.5%). Complications included intestinal atresia (36.4%) and foetal anaemia (9.1%). The overall perinatal mortality rate was 14.5%.

CONCLUSION

Foetal volvulus is a rare condition with high rates of preterm birth and perinatal mortality. Intestinal malrotation and cystic fibrosis are common predisposing causes, although the majority are idiopathic. Bowel and/or gastric dilatation is by far the most common sonographic finding.

Ultrasound for the diagnosis of malrotation and volvulus in children and adolescents: a systematic review and meta-analysis

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.

Saline-Aided Ultrasound Versus Upper Gastrointestinal Series in Neonates and Infants With Suspected Upper Gastrointestinal Obstruction: A Prospective Multicenter Comparative Study

Background: Use of upper gastrointestinal (UGI) series to diagnose UGI obstruction has raised concern in neonates and infants given increased radiation sensitivity by developing organs. Objectives: To assess the diagnostic performance of saline-aided ultrasound for UGI obstruction in neonates and infants, in comparison with UGI series. Methods: This prospective multicenter study enrolled inpatients at three hospitals who were less than 1 year old and had suspected UGI obstruction between June 2015 and May 2018; patients with malrotation or pyloric stenosis on ultrasound were ineligible. Enrolled patients underwent both saline-aided ultrasound (saline administered by nasogastric tube) and UGI series. Surgical findings or at least one-year clinical follow-up served as reference for presence of UGI obstruction. Patients with UGI obstruction were classified in terms of level (proximal vs distal) and cause. Two radiologists independently interpreted saline-aided US examinations to assess interobserver agreement and then reached consensus. Two separate radiologists assessed upper GI series in consensus. Diagnostic performance for UGI obstruction presence and level was compared between modalities. Causes were assessed on saline-aided ultrasound. Results: A total of 209 neonates were included (median age 5 days; 116 male, 93 female); 124 (59.3%) had UGI obstruction (proximal in 108). Saline-aided ultrasound exhibited strong interobserver agreement for obstruction presence (κ=0.87) and level (κ=0.85). For presence of UGI obstruction, accuracy, sensitivity, and specificity were 94.7%, 98.4%, and 89.4% for saline-aided US, versus 89.5%, 95.2%, and 81.5% for UGI series. For obstruction level, accuracy, sensitivity, and specificity were 91.9%, 97.2%, and 56.3% for saline-aided US, versus 87.1%, 92.6%, and 50.0% for UGI series. Accuracy for presence was significantly higher for saline-aided US (p=.02); otherwise, these metrics were not different between tests (p>.05). For causes of UGI obstruction (annual pancreas, duodenal web, duodenal atresia, and duodenal stenosis), accuracy of saline-aided US ranged from 75.0% to 94.1%. Conclusion: Saline-aided US has high diagnostic performance for presence and level of UGI obstruction in neonates and infants, comparing favorably versus UGI series. Saline-aided US may have additional utility in evaluating causes of obstruction. Clinical Impact: Saline-aided US may serve as an initial screening modality for UGI obstruction in neonates and infants.

A comprehensive radiologic review of abdominal and pelvic torsions

The clinical manifestations of abdominal and pelvic organ torsion can often be non-specific and can affect a wide range of ages and demographic groups. Radiologists have a key role in not only establishing the diagnosis of organ torsion, but also in the assessment of potential complications. As multiple imaging modalities may be utilized in the evaluation of abdominal and pelvic pain, recognizing the various appearances of organ torsion is important to ensure early diagnosis and thereby reducing patient morbidity and mortality, particularly since abdominal and pelvic organ torsion may not be clinically suspected at the time of initial patient presentation.

CT facilitates improved diagnosis of adult intestinal malrotation: a 7-year retrospective study based on 332 cases

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.

Untwisting the complexity of midgut malrotation and volvulus ultrasound

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.

Mesenteric Vessel Abnormalities Detected With Sonography: A Possible Gateway to the Early Diagnosis of Various Gastrointestinal Anomalies

Background:

In pediatric sonography, mesenteric vessel abnormalities can be used as a sign of malrotation or volvulus. This study was aimed at evaluating the diseases associated with mesenteric vessel abnormalities in children, except for rotational anomalies.

Methods:

From 2017 to 2020, pediatric patients with abdominal complaints were referred for a full abdominal sonogram and were evaluated for mesenteric vascular abnormalities. During this period, 62 children (aged <12 years), with mesenteric vessel abnormalities, were discovered with sonography. They were also examined for associated anomalies and were followed until a final diagnosis was determined.

Results:

Mesenteric vessel displacement was reported in 37 patients (60%); in 24 cases, the vein was located to the left of superior mesenteric artery (SMA), and in others (13 cases), in the anterior position. Abnormal pathways in mesenteric vessels were reported in 33 patients (53%); 18 cases showing a right side turn and 15 cases showing a left side turn. The whirlpool sign was seen in 16 patients (27%). These three patterns of vessel abnormality were associated with disorders such as diaphragmatic hernia, bowel obstruction, and space occupying lesions (masses). The location of the mesenteric abnormality was in the proximal part of mesenteric vessels in 45 cases (72.5%) and in its distal part in 17 cases (27.5%). Malrotation (eight cases), obstruction, and volvulus were the most common causes of a distal abnormality.

Conclusions:

Mesenteric vessel abnormalities, noted with sonography, may not be exclusive to the diagnosis of malrotation and midgut volvulus. In this cohort, bowel obstruction, diaphragmatic hernia, and space occupying lesions were the other most common anomalies associated with mesenteric vessel abnormalities. In reviewing one-third of mesenteric vessels, abnormalities were only seen in the distal part of vessels; therefore, a thorough examination is warranted.

Making the diagnosis of midgut volvulus: Limited abdominal ultrasound has changed our clinical practice

PURPOSE

To assess the diagnostic accuracy of limited abdominal ultrasound (US) examination for midgut volvulus (MGV) and to evaluate how clinical practice has changed in a free-standing children's hospital leading to the near obsolescence of upper GI (UGI) studies for the diagnosis of MGV.

MATERIALS AND METHODS

All patients with suspected MGV who underwent abdominal US during 2016-2017 were identified using keyword search tools in the radiology information system. Retrospective, blinded image review was performed by a certificate of added qualification (CAQ), board certified pediatric radiologist. US images were evaluated for the presence of the superior mesenteric artery (SMA) cutoff sign and twisting of the bowel and mesentery around the SMA (whirlpool sign). The results were compared with the operative reports.

RESULTS

195 US studies were performed from 2016 to 2017. The most common presentations were vomiting (44%), abdominal pain (7%), and suspected malrotation (10%) 195 US studies were reviewed, of which 16 were nondiagnostic. The remaining 179 diagnostic studies showed MGV in 14 patients. Those 14 patients were surgically explored and confirmed to have midgut volvulus. 7 of the 16 nondiagnostic US studies were further evaluated with UGI examination with 1 patient demonstrating malrotation without volvulus, which was confirmed at surgery. 2 had CT exams which were normal. 4 were followed clinically. The remaining 3 patients went to surgery, all of which did not show MGV. There were 164 negative US, none of whom went to surgery. US was diagnostic in 92% of patients and when diagnostic the positive and negative predictive values of US were 100%.

CONCLUSION

Limited abdominal US is a highly accurate examination for the diagnosis of midgut volvulus. UGI exposes patients to ionizing radiation and should be reserved for patients in whom US is nondiagnostic or inconclusive.

TYPE OF STUDY

Retrospective review.

LEVEL OF EVIDENCE

Level 3.

Time-Driven Activity-Based Cost Comparison of Three Imaging Pathways for Suspected Midgut Volvulus in Children

OBJECTIVE

To use time-driven activity-based costing to compare the costs of pathways for evaluating suspected pediatric midgut volvulus using either fluoroscopic upper gastrointestinal examination (UGI) or focused abdominal ultrasound (US).

METHODS

Process maps were created through patient shadowing, medical record review, and frontline staff interviews. Using time-driven activity-based costing methodology, practical capacity cost rates were calculated for personnel, equipment, and facility costs. Supply costs were included at institutional purchase prices. The cost of each process substep was determined by multiplying step-specific capacity costs by the median time required for each step, and substep costs were summed to generate total pathway cost. Multivariate sensitivity analyses were performed applying minimum and maximum labor costs. Assuming UGI would be used to troubleshoot nondiagnostic US, a break-even analysis was performed to determine the cost impact of varying frequencies of UGI on the total cost of the US-based pathway.

RESULTS

Process maps were created from 105 (48 girls, 57 boys) patient encounters. Base case pathway times were 90 min (UGI) and 55 min (US). Base case cost for UGI was $282.74 (range: $170.86-$800.82) when performed by a radiology practitioner assistant and $545.66 (range: $260.97-$1,974.06) when performed by a radiologist. Base case cost for US was $155.67 (range: $122.94-$432.29) when performed by a sonographer and $242.64 (range: $147.46-$1,330.05) when performed by a radiologist. For a US-based pathway, the total cost break-even pathway mix (percent UGI required for troubleshooting) was 57%.

CONCLUSION

US can be a faster and less costly alternative to UGI in pediatric patients with suspected midgut volvulus.

The role of sonography in differentiating congenital intrinsic duodenal anomalies from midgut malrotation: emphasizing the new signs of duodenal and gastric wall thickening and hyperechogenicity

BACKGROUND

The clinical and plain radiographic differentiation of congenital intrinsic duodenal anomalies (atresia, web, stenosis) from intestinal malrotation is not always clear. Although sonography has been documented as an important diagnostic tool in the differentiation of these two entities, its role is still not widely appreciated and it is still not universally utilized in this clinical setting.

OBJECTIVE

To assess the usefulness of sonographic features of the duodenal and gastric wall in the differentiation of congenital intrinsic duodenal anomalies from midgut malrotation in a large series of neonates and to compare them with other features on abdominal radiographs, ultrasound and upper gastrointestinal series.

MATERIALS AND METHODS

Using the surgical database at our tertiary pediatric hospital, we identified neonates who had surgically proven congenital intrinsic duodenal anomalies or malrotation over a period of 15 years (2000-2015). We reviewed imaging findings in both groups of neonates (blinded to the final diagnosis) with attention to the echogenicity and thickness of the wall of the duodenum and stomach, the relationship between the superior mesenteric artery and vein, the position of the third portion of the duodenum and the presence of the whirlpool sign. Findings were compared between the groups using the unpaired t-test and Fisher exact test.

RESULTS

We included 107 neonates in the study, 40 with a congenital intrinsic duodenal anomaly, 49 with malrotation (36 with volvulus) and 18 with a combination of both. Duodenal and gastric wall thickening and hyperechogenicity were significantly more common in the group with a congenital intrinsic duodenal anomaly compared to those with malrotation (P<0.0001). Conversely, an abnormal relationship between the superior mesenteric artery and vein, abnormal position of the third part of the duodenum, and the whirlpool sign were significantly more common in neonates with malrotation than in those with congenital intrinsic duodenal anomalies (P<0.0001).

CONCLUSION

Duodenal or gastric wall thickening, and increased wall echogenicity are helpful sonographic features in the differentiation of congenital intrinsic duodenal anomalies from malrotation. Evaluation of the duodenal and gastric wall should thus be added to the features routinely assessed on ultrasound examinations in the clinical setting of suspected duodenal obstruction in the neonate.

Use of ultrasound findings to predict bowel ischemic changes in pediatric patients with intestinal volvulus

OBJECTIVES

Early diagnosis and prompt surgical intervention are important to prevent intestinal necrosis in patients with volvulus. The purpose of this study was to determine which ultrasound (US) findings may predict bowel ischemic changes in pediatric patients with intestinal volvulus.

METHODS

Thirty-one pediatric patients with surgically proven intestinal volvulus were retrospectively reviewed. We compared the demographics and US findings (eg, superior mesenteric artery collapse, ascites, echogenic ascites, and degree of intestinal twist) between patients with and without bowel ischemic changes during surgery. Data are presented as median and range. The Fisher exact test, Mann-Whitney U test, and Wilcoxon signed rank sum test were used for statistical analyses.

RESULTS

Eleven patients had bowel ischemic changes. Significant differences existed between patients with and without ischemic changes for age (2 days [range, 0-137 days] versus 6.5 days [range, 2-1618 days]; P = .02), superior mesenteric artery collapse (present/absent, 10/1 versus 9/11 patients; P = .02), the presence of ascites (present/absent, 8/3 versus 6/14 patients; P = .03), and intestinal twist degree on US imaging (540° [range, 180°-720°] versus 360° [range, 180°-720°]; P = .02). The groups did not significantly differ for sex, the time from the US examination to the operation, or echogenic ascites. The intestinal twist degree insignificantly differed between US and surgical findings (360° [range, 180°-720°] versus 360° [range, 0°-1080°]; P = .36).

CONCLUSIONS

The presence of superior mesenteric artery collapse, ascites, and a large intestinal twist on US imaging were significant predictors of intestinal ischemic changes. Pediatric surgeons should perform prompt surgical interventions in cases of volvulus with these US findings.

The role of sonography for depiction of a whirlpool sign unrelated to midgut malrotation in neonates

BACKGROUND

The sonographic whirlpool sign of volvulus due to midgut malrotation is well recognized. However, variations of the whirlpool sign may be seen in other conditions, but this observation has received little attention in the literature.

OBJECTIVE

This study presents a series of neonates with a variety of causes of congenital intestinal obstruction, all associated with a whirlpool sign (unrelated to midgut volvulus), which was correctly recognized preoperatively on sonography. We also emphasize the pivotal role of sonography in managing congenital obstruction of the intestinal tract in neonates.

MATERIALS AND METHODS

This is a retrospective analysis of clinical, imaging and surgical findings in 11 neonates with congenital intestinal obstruction associated with a whirlpool sign (unrelated to midgut volvulus) that was recognized preoperatively on sonography and in whom the cause for the whirlpool was documented at surgery.

RESULTS

Eleven neonates (eight male, three female) had clinical and radiographic evidence of intestinal obstruction in whom sonography depicted a whirlpool sign, which was recognized on the initial sonogram in nine and on a repeat sonogram in two. The whirlpool was located in the upper abdomen in only two, mid-abdomen in five and right lower quadrant in four. The whirlpool was only 1-2 cm in diameter. An upper gastrointestinal series in three neonates failed to depict the cause of obstruction. Contrast enema in three cases had findings suggesting the site of obstruction was in the ileum but none depicted the exact cause of the obstruction. At surgery, the whirlpool sign correlated with a segmental volvulus of the small intestine in eight neonates and with the coiled distal small intestine associated with apple-peel atresia in the other three.

CONCLUSION

This study illustrates neonates in whom a whirlpool sign (unrelated to midgut volvulus) was correctly recognized on sonography before surgery. Sonography proved more useful than an upper gastrointestinal series or contrast enema in depicting the exact cause of the obstruction. Pediatric radiologists must make the effort to search throughout the entire abdomen and pelvis for a small whirlpool sign on sonography, even in the absence of midgut malrotation, in neonates with congenital intestinal obstruction. Its recognition preoperatively will facilitate a rapid diagnosis and will obviate the necessity for contrast examinations of the gastrointestinal tract, which require ionizing radiation.

Diagnostic Accuracy of Ultrasound for the Directionality of Testicular Rotation and the Degree of Spermatic Cord Twist in Pediatric Patients With Testicular Torsion

OBJECTIVES

To evaluate the diagnostic accuracy of ultrasound (US) to diagnose the directionality of testicular rotation and the degree of spermatic cord twist in pediatric patients with testicular torsion.

METHODS

A retrospective review of 14 pediatric patients with testicular torsion was conducted. The directionality of testicular rotation was classified as an inner or outer direction (inner, counterclockwise in the left testis [viewed from below] and clockwise in the right testis; and outer, counterclockwise in the right testis and clockwise in the left testis). The Clopper-Pearson method and the Fisher exact, Mann-Whitney U, and Wilcoxon signed rank sum tests were used for the statistical analyses.

RESULTS

The diagnostic accuracy of US in the directionality of testicular rotation and the degree of spermatic cord twist were 78.6% (11 of 14; 95% confidence interval, 49.2%-95.3%) and 36.4% (4 of 11; 95% confidence interval, 10.9%-69.2%), respectively. Outer rotation was seen in 50.0% of the cases. The directionality of testicular rotation and the degree of spermatic cord twist as determined by US were not significantly different between the patients with salvaged testis and those with testicular loss (inner/outer direction, 4/2 versus 4/4; P = .627; mean twist ± SD, 330.0° ± 73.5° versus 337.5° ± 115.4°; P > .999). There was no significant difference in the degree of spermatic cord twist determined by US and surgical results (343.0° ± 97.1° versus 458.2° ± 168.2°; P = .063).

CONCLUSIONS

The accuracy of US in determining the directionality of testicular rotation was relatively high in our small cohort. This information may be useful for pediatric surgeons and urologists when performing early manual reduction for testicular torsion.

Recurrent midgut volvulus in an adult patient - The case for pexy? A case report and review of the literature

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Intestinal malrotation and midgut volvulus in adulthood are rare events.

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Reports of recurrence among adults are very scarce. The rate of recurrence and optimal surgical management are yet to be determined.

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Bowel fixation procedures may be considered in Ladd procedures for adult midgut volvulus in order to reduce recurrence.

Introduction

Intestinal malrotation is a rare condition, with an incidence estimated between 0,2 to 1%. Most cases are diagnosed and treated during childhood. Adult presentations are rare and most adults present with chronic nonspecific complaints.

Midgut volvulus is the most feared complication of intestinal malrotation, far more common among the pediatric than the adult population. Presentation in adulthood with a midgut volvulus accounts for a minority of these patients (15%).

The Ladd procedure is the standard surgical management of midgut volvulus and intestinal malrotation. Most evidence on the outcomes of the Ladd procedure originates from studies on pediatric population and the recurrence among children who have had a Ladd procedure is low (2–7%).

Presentation of case

We report an exceedingly rare case of a patient who presented in adulthood with a midgut volvulus and less than two years after undergoing Ladd procedure presented with a recurrence of the midgut volvulus. The recurrent midgut volvulus was successfully treated by a fixation procedure (cecopexy and duodenopexy).

Conclusion

Reports of midgut volvulus in adult patients are scarce and reports of recurrence even scarcer hence the rate of recurrence among adult patients has yet to be determined. The recurrence rate in some of the available adult series is much higher than the rate reported among children.

Should the rate of recurrence among adult patients prove higher, it poses the question of whether the Ladd procedure should be modified to include bowel fixation when performed in adults.

Whirl Sign and Midgut Volvulus: An Unusual Cause of an Acute Abdomen in an Adult Patient

We report the case of a 50-year-old lady who presented to the emergency department complaining of a two-day history of colicky right upper quadrant (RUQ) pain, which radiated through to her back, associated with nausea, anorexia, and two episodes of vomiting that day. She was found to be tender in the RUQ. Her blood tests were notable for an elevated white cell count. Initial impression was of acute cholecystitis. Ultrasound of her abdomen did not identify any features of acute cholecystitis; however, a large volume of free fluid was identified within the abdomen. CT of the abdomen/pelvis was obtained which identified dilated loops of small bowel, interloop ascites, and a whirl sign highly suggestive of midgut volvulus. During laparoscopy, the midgut volvulus was found to have resolved. No cause for the volvulus could be identified, and the patient was discharged home well on postoperative day two.

Prenatal diagnosis of antenatal midgut volvulus: Specific ultrasound features

OBJECTIVE

To assess specific, direct, and indirect prenatal ultrasound features in cases of fetal midgut volvulus.

METHODS

Retrospective case series of neonatal volvulus, based on postnatal and prenatal imaging findings that occurred from 2006-2017. Prenatal and postnatal signs including the specific "whirlpool sign" were computed. Postnatal volvulus was confirmed by pathology examination after surgery or neonatal autopsy.

RESULTS

Thirteen cases of midgut volvulus were identified. Though not a specific sign, a decrease in active fetal movements was reported in eight patients (61.5%). The prenatal whirlpool sign was directly seen in 10 cases, while an indirect but suggestive sign, a fluid-filled level within the dilated loops, was present in five cases. No intestinal malrotation was observed. Pregnancy outcomes were two terminations of pregnancy, both associated with cystic fibrosis, one early neonatal death, three prenatal spontaneous regressions, and seven favorable outcomes after neonatal surgery with resection of midgut atresia.

CONCLUSIONS

Identification of the whirlpool sign or of a fluid-filled level within the dilated loops improves the accuracy of ultrasound findings for suspected volvulus. In the absence of total volvulus (in cases of intestinal malrotation) or association with cystic fibrosis, the prognosis appears good.

Malrotation Induced Small Intestine Ischemia in an Adolescent

Intestinal malrotation occurs if midgut does not complete or partially completes its 270° counter-clockwise rotation around the superior mesenteric artery during embryologic life. In general, it frequently manifests with vomiting due to duodenal obstruction and volvulus in the initial months of life, and it is very rare to manifest in the adulthood. A 20-year-old male patient who had severe abdominal pain, nausea, vomiting, and distention for one day was evaluated at the emergency department. On abdominal tomography "swirling appearance of structures around the superior mesenteric artery" was reported. CT appearance was considered compatible with a rotational anomaly. Emergency surgery was planned for the patient. In laparotomy, it was observed that an approximately 100 cm long small intestine segment was rotated around a band (Ladd) and ischemia was developed in this segment due to rotation of its mesentery. The rotation of the small intestinal mesentery was corrected by opening the bands. After the warm application to the intestinal mesenteric ischemia for a while, the color and the peristalsis of the intestines became normal. The patient was discharged on postoperative day 2 with suggestions.

Role of upper gastrointestinal contrast studies for suspected malrotation in neonatal population

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.

Rare small intestinal volvulus from entrapment in hepato-diaphragmatic adhesions in a 45-year-old lady

Small intestinal volvulus is rare in adults and rarely caused by string adhesions between the liver and the diaphragm. Similar adhesions were described in Fitz-Hugh-Curtis syndrome. We report a 45-year-old lady with small intestinal volvulus from entrapment of a loop in string adhesions between the liver and the diaphragm. Her plain radiographs showed a significant shadow of the trapped loop.

Volvulus of ileum: a rare cause of small bowel obstruction

Small bowel volvulus is a rare but life-threatening surgical emergency. Owing to its rarity, it is seldom entertained as a differential for small bowel obstruction. The aetiology may be either primary or secondary, with secondary being more common in the Western world. Prompt diagnosis and urgent surgical treatment is required if bowel necrosis is to be prevented, which is associated with increased mortality. We present a case of primary ileal volvulus with a gangrenous segment and a brief overview of the current literature.

A Curious Case of Right Upper Quadrant Abdominal Pain

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.

Primary adult midgut volvulus mimicking acute appendicitis: A case report and review of the literature

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Adult midgut volvulus is a rare but important cause of small bowel obstruction.

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Our patient, 35 year old male, was clinically suspected to have acute appendicitis.

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Intra-operatively, we found a normal appendix and jejunal volvulus with adhesions.

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If in doubt, early contrast CT scan should be performed.

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Delay to diagnosis and surgical intervention may result in bowel ischemia.

Introduction

Adult midgut volvulus is a rare surgical disease but remains an important cause of small bowel obstruction. It is most commonly secondary to postoperative adhesions. Primary cases may be due to congenital malformations.

Presentation of case

We report the case of an adult primary midgut volvulus in a 35-year-old Chinese male. Based on the clinical presentation and investigations, the patient was presumed to have acute appendicitis. An open appendectomy was performed. During the operation, the appendix appeared normal. Instead a jejunal volvulus was found secondary to extensive adhesions.

Discussion

The epidemiology, embryology and etiology of jejunal volvulus are highlighted. Clinical presentation includes acute colicky abdominal pain usually in the peri-umbilical or epigastric regions, with possible signs of small bowel obstruction. Radiologic diagnosis is confirmed with the ultrasonic ‘whirpool’ sign or via computed tomography (CT) scan. Early surgical intervention is necessary to avert bowel ischemia in the presence of a closed loop obstruction.

Conclusion

While rare, adult midgut volvulus has the potential for morbidity and mortality if not diagnosed early with intestinal ischaemia and related sequlae. Clinicians should consider this and if in doubt, perform an early contrast CT scan.

Usefulness of Sonography in Evaluating Children Suspected of Malrotation: Comparison With an Upper Gastrointestinal Contrast Study

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.

Ultrasonographic diagnosis of midgut volvulus with malrotation in children

OBJECTIVES

Midgut volvulus with malrotation is typical in newborns. We present our experience to emphasize the importance of suspecting midgut volvulus as a cause of abdominal pain also beyond infancy, particularly in relation to malrotation, and the relevance of ultrasonographic (US) signs in its diagnosis.

METHODS

A total of 34 patients (10 boys, 24 girls; ages between 1 day and 12 years) diagnosed as having malrotation or malrotation with volvulus, surgically confirmed, between 2006 and 2013 were retrospectively selected among all of the patients referred to our institution for acute abdomen and bilious vomiting. All of them underwent US and color Doppler examination before surgery. The US examinations were performed with 6 to 10 MHz microconvex and 7.5 to 10 Mhz linear transducer. The transducer was placed under xiphoid, and, with axial projection, the presence of anatomic position reversed between superior mesenteric vein (SMV) and superior mesenteric artery (SMA), as a sign of malrotation, and the presence of "whirlpool sign" (WS) (wrapping of the SMV and the mesentery around the SMA), as a sign of midgut volvulus, were evaluated.

RESULTS

In 27 of these 34 patients, midgut volvulus was present; 7 patients had intestinal malrotation. In 2 of 7 (28%) patients with malrotation, SMA and SMV were inverted. Among the patients with volvulus, 2 showed reversed vessel position and 22 patients presented the WS in association with SMA/SMV inversion (22/27, 81%).

CONCLUSIONS

Midgut volvulus with malrotation can appear beyond the neonatal age group as demonstrated in our case. The WS sign is sufficiently sensitive for its diagnosis and should be routinely researched at all ages of pediatric population. Anatomic inversion between SMV and SMA seems to be not enough sensitive in isolated malrotation diagnosis.

Disorders of midgut rotation: making the correct diagnosis on UGI series in difficult cases

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.

Primary mesenteric lymphangioma in a young adult with intestinal malrotation and 'counter-clockwise barber pole sign'

Mesenteric lymphangiomas are uncommon benign lesions that usually occur in isolation but rarely may be associated with gastrointestinal (GI) malrotation. Malrotation may cause chronic and recurrent volvulus leading to chronic venous congestion and lymphatic engorgement. Interference with lymphatic drainage may result in formation of a lymphangioma or a chylous mesenteric cyst. In our case, mesenteric lymphangioma was present with partial malrotation of small and large bowel. There was no radiological and surgical evidence of volvulus, favouring the hypothesis that lymphangioma may be a primary congenital association of GI malrotation. Another interesting finding was the counter-clockwise twisting of the superior mesenteric vein around the superior mesenteric artery which has been reported only seven times in the literature.

[Midgut volvulus in a 70-year-old man due to intestinal nonrotation]

Intestinal malrotation is a congenital disorder that results from the failure of normal bowel rotation and fixation during the 5th gestational week. The incidence of intestinal malrotation is <0.2%, but prompt diagnosis is important because this anomaly can cause midgut volvulus and lead to fatalities. Compared to infants presenting with acute symptoms, such as abdominal pain, vomiting, or diarrhea, adult patients complain of intermittent self-limited abdominal pain. We present a case of intestinal malrotation complicated by midgut volvulus improved with conservative care in a 70-year-old man. The diagnosis was suggested on the basis of imaging findings.