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Girolamo M, Emanuela G, Yu WMC, Anna M, Marta P, Grazia CM, Gandullia P, Arrigo S, Stefano A, Beatrice DM. Diagnostic accuracy of upper gastrointestinal series in children with suspected intestinal malrotation. Updates Surg 2024; 76:201-208. [PMID: 37326933 PMCID: PMC10806024 DOI: 10.1007/s13304-023-01559-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 06/03/2023] [Indexed: 06/17/2023]
Abstract
Intestinal malrotation (IM) results from an altered or incomplete rotation of the fetal midgut around the superior mesenteric artery axis. The abnormal anatomy of IM is associated with risk of acute midgut volvulus which can lead to catastrophic clinical consequences. The upper gastro-intestinal series (UGI) is addressed as the gold standard diagnosis procedure, but a variable failure degree has been described in literature. The aim of the study was to analyze the UGI exam and describe which features are the most reproducible and reliable in diagnosing IM. Medical records of patients surgically treated for suspected IM between 2007 and 2020 at a single pediatric tertiary care center were retrospectively reviewed. UGI inter-observer agreement and diagnostic accuracy were statistically calculated. Images obtained with antero-posterior (AP) projections were the most significant in terms of IM diagnosis. Duodenal-Jejunal Junction (DJJ) abnormal position resulted to be the most reliable parameter (Se = 0.88; Sp = 0.54) as well as the most readable, with an inter-reader agreement of 83% (k = 0.70, CI 0.49-0.90). The First Jejunal Loops (FJL), caecum altered position and duodenal dilatation could be considered additional data. Lateral projections demonstrated an overall low sensitivity (Se = 0.80) and specificity (Sp = 0.33) with a PPV of 0.85 and a NPV of 0.25. UGI on the sole AP projections ensures a good diagnostic accuracy. The position of the third portion of the duodenum on lateral views showed an overall low reliability, therefore it was not helpful but rather deceiving in diagnosing IM.
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Affiliation(s)
- Mattioli Girolamo
- University of Genoa, DINOGMI, Genoa, Italy
- Pediatric Surgery Unit, IRCCS, Istituto Giannina Gaslini, Via G. Gaslini 5, 16147, Genoa, Italy
| | | | - Wong Michela Cing Yu
- Pediatric Surgery Unit, IRCCS, Istituto Giannina Gaslini, Via G. Gaslini 5, 16147, Genoa, Italy.
- , Via Gerolamo Gaslini, 5, 16148, Genoa, Italy.
| | - Marzoli Anna
- Radiology Unit, IRCCS, Istituto Giannina Gaslini, Via G. Gaslini 5, 16147, Genoa, Italy
| | - Pongiglione Marta
- Radiology Unit, IRCCS, Istituto Giannina Gaslini, Via G. Gaslini 5, 16147, Genoa, Italy
| | - Calevo Maria Grazia
- Epidemiology and Biostatistics Unit, Scientific Direction, IRCCS Istituto Giannina Gaslini, Via G. Gaslini 5, 16147, Genoa, Italy
| | - Paolo Gandullia
- Pediatric Gastroenterology and Endoscopy Department, IRCCS, Istituto Giannina Gaslini, 16147, Genoa, Italy
| | - Serena Arrigo
- Pediatric Gastroenterology and Endoscopy Department, IRCCS, Istituto Giannina Gaslini, 16147, Genoa, Italy
| | - Avanzini Stefano
- Pediatric Surgery Unit, IRCCS, Istituto Giannina Gaslini, Via G. Gaslini 5, 16147, Genoa, Italy
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Singh U, Baker A. Midgut malrotation: a rare presentation of bowel obstruction in the adult. J Surg Case Rep 2021; 2021:rjab309. [PMID: 34316348 PMCID: PMC8302075 DOI: 10.1093/jscr/rjab309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 06/19/2021] [Indexed: 01/21/2023] Open
Abstract
Intestinal malrotation is a rare congenital abnormality. Usually, patients with malrotation of the intestine present in the neonatal period or the first year of life while some may remain asymptomatic and present later in childhood or adulthood. The diagnosis is usually delayed due to the sequence of events being that of non-specific gastrointestinal symptoms, which culminates in either adhesive bowel obstruction or volvulus. A 59-year-old male diagnosed with a large, incarcerated, right inguinoscrotal hernia underwent emergency laparotomy, which revealed midgut malrotation and small bowel obstruction due to Ladd bands. A modified Ladd’s procedure and right inguinal herniorrhaphy was performed.
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Affiliation(s)
- Ulanda Singh
- Department of Surgery, University Hospital of the West Indies, Mona, Jamaica
| | - Akil Baker
- Department of General Surgery, University Hospital of the West Indies, Mona, Jamaica
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Incidental diagnosis of true intestinal malrotation. Tech Coloproctol 2020; 24:771-772. [PMID: 32246249 DOI: 10.1007/s10151-020-02198-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 03/29/2020] [Indexed: 10/24/2022]
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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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Chiapponi C, Jannasch O, Petersen M, Lessel W, Bruns C, Meyer F. A rare case of perforated "sub-hepatic appendicitis" - a challenging differential diagnosis of acute abdomen based on the combination of appendicitis and maldescent of the caecum. Pathol Res Pract 2016; 213:75-78. [PMID: 27908462 DOI: 10.1016/j.prp.2016.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Revised: 03/02/2015] [Accepted: 11/09/2016] [Indexed: 11/26/2022]
Abstract
Unusual locations of the appendix vermiformis can result in delay in appropriate diagnosis and treatment of appendicitis. So an inflamed appendix in a sub-hepatic caecum caused by caecal maldescent for example can mimic cholecystitis, the pain being localized in the right upper quadrant. Here, we present a case of perforated sub-hepatic appendicitis with peritonitis, requiring open ileocaecal resection. Review of the existing literature has demonstrated that this pathology is uncommon, yet not so rare as one might presume. In conclusion, surgeons should be aware of this possibility in the diagnostic and therapeutic management of acute abdomen.
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Affiliation(s)
- Costanza Chiapponi
- Dept. of General, Abdominal and Vascular Surgery, University Hospital of Magdeburg, Germany.
| | - Olof Jannasch
- Dept. of General, Abdominal and Vascular Surgery, University Hospital of Magdeburg, Germany
| | - Manuela Petersen
- Dept. of General, Abdominal and Vascular Surgery, University Hospital of Magdeburg, Germany
| | - Wiebke Lessel
- Institute of Pathology, University Hospital, Magdeburg, Germany
| | - Christiane Bruns
- Dept. of General, Abdominal and Vascular Surgery, University Hospital of Magdeburg, Germany
| | - Frank Meyer
- Dept. of General, Abdominal and Vascular Surgery, University Hospital of Magdeburg, Germany
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