Sonographic features related to volvulus in neonatal intestinal malrotation

High risk and low incidence diseases: Pediatric digestive volvulus

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.

Intrauterine volvulus: systemic review of the literature with pooled analysis

Our objective is to analyse the observations related to intrauterine volvulus and assess how clinical manifestations and treatment strategies impact prognosis. We conducted a comprehensive search on Pubmed and ClinicalTrials.gov from inception to July 2022, using search terms like "intrauterine volvulus" or "foetal volvulus," supplemented by manual scrutiny of reference lists in relevant texts and articles. Our review encompassed 57 case reports/case series, involving 88 cases. The presence of foetal bradycardia during prenatal visits (p = 0.002) and the existence of meconium cyst or pseudocyst (p = 0.038) significantly influence survival rates. Preterm labour occurred more frequently among cases resulting in mortality (54% vs 21%; p = 0.055). Our study's limitations include the inability to access all reported cases and reliance solely on available data. We advocate for vigilant monitoring of foetuses exhibiting signs of intestinal obstruction, and consideration of an emergent caesarean section as a pre-emptive measure before foetal biophysical profile deterioration worsens.

Radiographic and ultrasonographic appearance of a jejunal torsion-volvulus in a dog

A 1.5-year-old male neutered, 5 kg, Dachshund was referred for anorexia and vomiting for several days' duration. Radiographs revealed concern for a small intestinal obstruction. Ultrasonography revealed a severely distended segment of jejunum containing echogenic fluid that abruptly narrowed, twisted, and transitioned into normal jejunum, along with the presence of a distinct "whirl sign" that resulted from the intestinal segments twisting around themselves. This, in addition to the absence of flow on power Doppler interrogation, was compatible with a focal jejunal torsion-volvulus. The torsion-volvulus was surgically confirmed, a resection and anastomosis was performed, and the dog recovered uneventfully.

Neonatologist-performed point-of-care abdominal ultrasound: What have we learned so far?

This review describes the sonographic appearances of the neonatal bowel in Necrotising enterocolitis. It compares these findings to those seen in midgut-Volvulus, obstructive intestinal conditions such as milk-curd obstruction, and slow gut motility in preterm infants on continuous positive airway pressure (CPAP)-CPAP belly syndrome. Point-of-care bowel ultrasound is also helpful in ruling out severe and active intestinal conditions, reassuring clinicians when the diagnosis is unclear in a non-specific clinical presentation where NEC cannot be excluded. As NEC is a severe disease, it is often over-diagnosed, mainly due to a lack of reliable biomarkers and clinical presentation similar to sepsis in neonates. Thus, the assessment of the bowel in real-time would allow clinicians to determine the timing of re-initiation of feeds and would also be reassuring based on specific typical bowel characteristics visualised on the ultrasound.

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.

Sonographic diagnosis of malrotation: it's complicated - counterpoint

Focused abdominal sonography (US) has been suggested as a first-line modality for the diagnosis of malrotation and volvulus in newborns. In this paper, the author reviews the strengths and weaknesses of US in the diagnosis and exclusion of malrotation and volvulus. The author reviews published implementation programs for using US in both conditions and describes the anatomical variations that limit the utility of US depiction of a retromesenteric duodenum in the exclusion of malrotation.

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.

Ultrasound imaging as the first line of investigation to diagnose intestinal malrotation in children: Safety and efficacy

BACKGROUND

Upper gastrointestinal contrast study is considered the gold standard investigation to diagnose intestinal malrotation and midgut volvulus which is potentially devastating condition. Ultrasound imaging is an alternative but has been considered unreliable due to significant false negative results. At our institution we have been using ultrasound imaging as the first line investigation to diagnose malrotation since 2008 with a preliminary study of 139 patients published in 2014. This is an ongoing audit of a further much larger cohort of patients to determine the efficacy and safety of ultrasound imaging in the diagnosis of intestinal malrotation.

MATERIALS AND METHODS

Following ethics approval, a retrospective analysis of a prospectively collected patient database undergoing ultrasound scans to exclude malrotation at our centre was performed from 2012 to 2019.

RESULTS

539 patients underwent ultrasound to assess for malrotation. The mean age of presentation was 365 days (median 30 days, mode 1 day). Malrotation was diagnosed in 17 with 5 having volvulus, with findings confirmed at surgery. 12 had equivocal findings and subsequent contrast studies ruled out malrotation. The remaining 510 patients with no evidence of malrotation were managed conservatively.

CONCLUSION

We have shown ultrasound to be a safe and effective tool to assess intestinal malrotation without exposure to ionizing radiation.

LEVEL OF EVIDENCE

Level IV.

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.

Neonatal and Pediatric Bowel Obstruction: Imaging Guidelines and Recommendations

Pediatric bowel obstructions are one of the most common surgical emergencies in children, and imaging plays a vital role in the evaluation and diagnosis. An evidence-based and practical imaging approach to diagnosing and localizing pediatric bowel obstructions is essential for optimal pediatric patient care. This article discusses an up-to-date practical diagnostic imaging algorithm for pediatric bowel obstructions and presents the imaging spectrum of pediatric bowel obstructions and their underlying causes.

Intrauterine midgut volvulus as a rare cause of intestinal obstruction: a case report

Background

Intrauterine midgut volvulus is a very rare, life-threatening condition, and prenatal diagnosis is difficult. In this article, we present a case of midgut volvulus followed by a pre-diagnosis of antenatal jejunal atresia.

Case presentation

A 1-day-old Turkish male baby, who was followed with a diagnosis of antenatal jejunal atresia, with a birth weight of 3600 g, delivered by cesarean section at 38 weeks of gestation from a 19-year-old mother in her fourth pregnancy, was taken to the newborn intensive care unit. The patient underwent surgery on the postnatal first day with a preliminary diagnosis of jejunal atresia. It was observed that the small intestine was rotated two full cycles from the mesenteric root. Bowel blood circulation was good. Volvulus was untwisted. There was malrotation. Ladd's procedure was performed. The baby was discharged on the seventh postoperative day with full oral feeding. The patient is still in the first postoperative year and follow-up has been uneventful.

Conclusion

Intrauterine midgut volvulus has been associated with high mortality in the literature. Differential diagnosis of midgut volvulus in patients with antenatal intestinal obstruction, close prenatal follow-up, appropriate delivery and timing of surgical intervention may significantly reduce morbidity and mortality.

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.

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.

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.

Neonatologist performed point-of-care bowel ultrasound: Is the time right?

Introduction

This review acquaints neonatal clinicians using point-of-care ultrasound with a range of pathological bowel ultrasound findings, with the aim to promote utility of this skill as a diagnostic assessment tool in diseased neonatal intestinal states.

Overview

A range of normal and pathological bowel ultrasound findings are illustrated with case examples from our neonatal intensive care unit. The technical challenges of lack of familiarity with sonographic appearance of bowel (healthy and diseased), occurrence of gas artefacts and requirements of high-resolution linear transducer probes are described to allow the development of skills amongst neonatologists trained in point-of-care ultrasound. Plain abdominal radiography continues to remain the standard investigation to differentiate benign bowel states such as continuous positive airway pressure (CPAP) belly syndrome in preterm infants from life-threatening pathological intestinal states such as necrotising enterocolitis. Although plain radiography is the gold standard modality in the evaluation of neonatal diseased bowel states, real-time point-of-care bowel ultrasound performed in conjunction can provide valuable information on bowel peristalsis, bowel wall thickness and bowel vascularity. Abnormal configuration of superior mesenteric vessels on colour Doppler can alert the clinician to the diagnosis of neonatal intestinal malrotation-a time critical emergency.

Conclusion

Further research is needed to explore true-negative and true-positive predictive values of bowel ultrasound. However, with expansion of knowledge, appropriate training of techniques, neonatologists will be able to enhance their diagnostic acumen by performing point-of-care bowel ultrasound in conjunction with plain radiography in the evaluation of broad array of neonatal intestinal states.

Fetal Midgut Volvulus with Meconium Peritonitis Detected on Prenatal Ultrasound

Background

Fetal volvulus is a rare, yet life-threatening condition that requires skilful diagnosis and management. Volvulus occurs when bowel loops become twisted and the twisting of the mesenteric artery leads to congestion, impaired venous return, and bowel necrosis.

Case Description

We present a case of fetal ileal volvulus suspected on third trimester ultrasound, complicated by premature labour, small bowel necrosis, and meconium peritonitis. Progressive dilatation and decreased peristalsis of echogenic bowel were noted in the early part of the third trimester. Daily surveillance ultrasound was performed and spontaneous labour occurred at 32 weeks' gestation. A proactive postnatal approach guided by prenatal sonographic findings allowed prompt treatment and an urgent laparotomy was performed for an ileal volvulus with necrosis and meconium peritonitis. A segment of small bowel volvulus was resected and an end-to-end anastomosis was performed with uneventful recovery.

Discussion

Clinically signs of fetal midgut volvulus are not pathognomonic, such as intestinal dilatation, abdominal mass, ascites, peritoneal calcifications, or polyhydramnios; thus, the diagnosis is often challenging. Complications reported in the literature include perforation and haemorrhagic ascites, which may lead to anaemia, hypovolemia, heart failure, and fetal demise.

Conclusion

This case highlights the importance of assessing the fetal bowel as a part of routine third trimester ultrasound. The case describes the complexity of diagnosis in the fetus, important considerations along with multidisciplinary team approach to management.

The efficiency of sonography in diagnosing volvulus in neonates with suspected intestinal malrotation

This study is to prospectively evaluate the efficiency of sonography for volvulus diagnosis in neonates with clinically suspected intestinal malrotation.A total of 83 patients with suspected intestinal malrotation who underwent detailed abdominal sonography and upper gastrointestinal contrast study were included. Malrotation was characterized by inversion of the superior mesenteric artery (SMA) and superior mesenteric vein (SMV) in sonographic examination. The "whirlpool sign" of Color Doppler Sonography was recognized as a characteristic for malrotation with volvulus. The degrees of rotation of the SMV winding around SMA were also detected by sonography. Surgery was performed in patients with sonography diagnosed malrotation.A total of 39 patients were sonographically diagnosed as malrotation which was subsequently confirmed by surgery. The sensitivity and positive predictive value of the sonographic diagnosis were both 100% (39/39). The sensitivity, specificity and accuracy of "whirlpool sign" for the detection of midgut volvulus were 95.2% (20/21), 88.9% (16/18), and 92.3% (36/39), respectively. Greater degrees of rotation (equal or greater than 720°) showed higher risk (odds ratio, 5.0; P < .01) for intestinal necrosis occurrence.Sonography is more accurate in diagnosing suspected malrotation than upper gastrointestinal contrast study. Specific sonographic "whirlpool sign" related to volvulus may be used as a potential indicator for intestinal necrosis. In addition, sonography can exclude malrotation and may help the diagnosis of other diseases, such as annular pancreas and duodenal atresia.

Color Doppler-An effective tool for diagnosing midgut volvulus with malrotation

BACKGROUND

Malrotation with midgut volvulus is a common surgical emergency in children. A diagnostic tool for malrotation with characteristics ideal in emergency settings such as non-invasiveness and rapidity remains a keenly debated issue among surgeons and radiologists alike.

METHODS

Fifty-two pediatric patients of suspected malrotation with midgut volvulus were studied between 1998 and 2016. All patients underwent plain abdominal X-ray and Color Doppler; contrast upper gastrointestinal (GI) studywas done in some patients. All cases were operated and diagnosis was confirmed. A subset of 60 pediatric patients with nonspecific GI complaints were also examined to see relative position of superior mesenteric vein (SMV)/superior mesenteric artery (SMA) in control population.

RESULT

A total of 52 suspected cases of malrotation were admitted from May 1998 to November 2015, 43 had inversion of SMA/SMV and nine had SMV anterior of SMA in Color Doppler. All 43 cases of inversion of SMA/SMV were cases of malrotation after surgical confirmation; while five out of nine cases of SMV anterior to SMA had malrotation.

CONCLUSION

In appropriate clinical settings, Color Doppler documenting the reversal or aberrant SMV/SMA axis is not only predictive but also diagnostic of malrotation of gut.

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.

Volvulus in term and preterm infants - clinical presentation and outcome

AIM

Our aim was to assess if term and preterm infants with volvulus showed different patterns with regard to pathogenesis, clinical presentation and outcome.

METHODS

We reviewed the medical records and imaging data of infants aged less than six months with volvulus treated in a single surgical referral centre from 2006-2013.

RESULTS

Volvulus was diagnosed in 19 infants, with no anatomical anomaly in three of the 12 preterm infants and one of the seven term infants. Most cases (74%) presented during the first eight days of life. Later presentations occurred exclusively in preterm infants, with only one of the five having no anatomic anomalies. Bilious vomiting was the leading symptom in six of the seven term infants, while the symptoms in preterm infants were rather nonspecific. Intestinal necrosis, with the need for bowel resection, occurred in one term (14%) infant and nine (75%) preterm infants.

CONCLUSION

The clinical presentation and outcome of volvulus differed between preterm and term infants, but the rate and distribution of underlying anomalies did not differ. Symptoms in preterm infants were often nonspecific and led to a delay in diagnosis. This might have contributed to the higher rate of intestinal necrosis in preterm infants.

Comparative Effectiveness of Imaging Modalities for the Diagnosis of Intestinal Obstruction in Neonates and Infants:: A Critically Appraised Topic

RATIONALE AND OBJECTIVES

The purpose of this study was to critically appraise and compare the diagnostic performance of imaging modalities that are used for the diagnosis of upper and lower gastrointestinal (GI) tract obstruction in neonates and infants.

METHODS

A focused clinical question was constructed and the literature was searched using the patient, intervention, comparison, outcome method comparing radiography, upper GI contrast study, and ultrasound in the detection of upper GI tract obstruction such as duodenal atresia and stenosis, jejunal and ileal atresia, and malrotation and volvulus. The same methods were used to compare radiography and contrast enema in the detection of lower GI tract obstruction such as meconium plug syndrome, meconium ileus, Hirschsprung disease, and imperforate anus. Retrieved articles were appraised and assigned a level of evidence based on the Oxford University Centre for Evidence-Based Medicine hierarchy of validity for diagnostic studies.

RESULTS

There were no sensitivities/specificities available for the imaging diagnosis of duodenal atresia or stenosis, jejunal or ileal atresias, meconium plug, and meconium ileus or for the use of cross-table lateral radiography for the diagnosis of rectal pouch distance from skin in imperforate anus. The retrieved sensitivity for the detection of malrotation on upper GI contrast study is 96%, and the sensitivity for the diagnosis of midgut volvulus on upper GI contrast study is 79%. The retrieved sensitivity and specificity for the detection of malrotation with volvulus on ultrasound were 89% and 92%, respectively. The retrieved sensitivity and specificity for the detection of Hirschsprung disease on contrast enema were 70% and 83%, respectively. The retrieved sensitivity of invertogram for the diagnosis of rectal pouch distance from skin in imperforate anus is 27%. The retrieved sensitivities of perineal ultrasound and colostography for the diagnosis of rectal pouch distance from skin in imperforate anus were 86% and 100%, respectively.

CONCLUSIONS

There is limited evidence for the imaging diagnosis of duodenal atresia and stenosis, jejunal and ileal atresias, meconium plug, meconium ileus, and imperforate anus, with recommended practice based mainly on low-quality evidence or expert opinion. The available evidence supports the use of upper GI contrast study for the diagnosis of malrotation and volvulus, with ultrasound as an adjunct to diagnosis. Contrast enema is useful in the investigation of suspected Hirschsprung disease, but a negative study does not outrule the condition. Colostography is the investigation of choice for the work-up of infants with complex anorectal malformations before definitive surgical repair.

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.

Asymptomatic malrotation: Diagnosis and surgical management: An American Pediatric Surgical Association outcomes and evidence based practice committee systematic review

OBJECTIVE

Patients with malrotation, or an intestinal rotation abnormality (IRA), can experience serious adverse events. Increasingly, asymptomatic patients are being diagnosed with malrotation incidentally. Patients with symptomatic malrotation require surgery in an urgent or semiurgent manner to address their symptoms. The treatment of asymptomatic or incidentally discovered malrotation remains controversial.

METHODS

Data were compiled from a broad search of Medline, Cochrane, Embase and Web of Science from January 1980 through January 2013 for five questions regarding asymptomatic malrotation.

RESULTS

There is minimal evidence to support screening asymptomatic patients. Consideration may be given to operate on asymptomatic patients who are younger in age, while observation may be appropriate in the older patient. If reliably diagnosed, atypical malrotation with a broad-based mesentery and malposition of the duodenum can be observed. Regarding diagnostic imaging, the standard of care for diagnosis remains the upper gastrointestinal contrast study (UGI), ultrasound may be useful for screening. A laparoscopic approach is safe for diagnosis and treatment of rotational abnormalities. Laparoscopy can aid in determining whether a patient has true malrotation with a narrow mesenteric stalk, has nonrotation and minimal risk for volvulus, or has atypical anatomy with malposition of the duodenum. It is reasonable to delay Ladd procedures until after palliation on patients with severe congenital heart disease. Observation can be considered with extensive education for family and caregivers and close clinical follow-up.

CONCLUSIONS

There is a lack of quality data to guide the management of patients with asymptomatic malrotation. Multicenter and prospective data should be collected to better assess the risk profile for this complex group of patients. A multidisciplinary approach involving surgery, cardiology, critical care and the patient's caregivers can help guide a watchful waiting management plan in individual cases.

Fetal midgut volvulus: report of eight cases

OBJECTIVE

To evaluate whether prenatal diagnosis of intestinal midgut volvulus (a rare condition due to the small bowel loops twisting) can improve the prognosis of the newborns.

METHODS

In our Prenatal Diagnosis Center, eight cases of intestinal volvulus observed between 2007 and 2014 were retrospectively considered. Ultrasonographic signs can be direct and specific (whirlpool sign, coffee bean sign) or indirect and non-specific (abdominal mass, dilated bowel loops, pseudocysts, ascites, polyhydramnios).

RESULTS

Prenatal diagnosis was performed at 20-34 weeks of gestation. All newborns were exposed to an emergency surgery: the major complication was due to cystic fibrosis.

CONCLUSIONS

An early suspicion of intestinal volvulus allows the clinician to refer the patient to a tertiary center so to confirm the diagnosis and perform an appropriate follow-up in order to identify the proper time of delivery. The prognosis of the babies with prenatal intestinal volvulus depends on the length of the segment involved, on the level of intestinal obstruction, on the presence of meconium peritonitis and on the gestational age at birth. Our experience, according with the literature, suggests that ascites and absence of abdominal peristalsis are ultrasonographic signs that, in the third trimester of pregnancy, correctly lead to an immediate delivery intervention.

Sonography of the pediatric gastrointestinal system

Sonography is a commonly used modality for the investigation of abdominal symptoms in the pediatric population. It is a highly sensitive, readily available imaging modality that does not require ionizing radiation, iodinated contrast material, or anesthesia and can be performed at the bedside if necessary. Abdominal ultrasound is therefore often the first examination performed. This article presents an overview of the ultrasound characteristics of some of the most frequently encountered pathologies as well as some more rarely encountered entities. Our aim was to present a series of characteristic images of a wide gamut of pediatric abdominal conditions. The goal was to familiarize the reader with key sonographic features of both congenital and acquired gastrointestinal pathologies in children, making them more easily recognizable.

Common and uncommon applications of bowel ultrasound with pathologic correlation in children

OBJECTIVE

The purpose of this article is to describe the indications and techniques for bowel ultrasound for inflammatory bowel disease and other common and uncommon entities and describe and illustrate their imaging appearances, including endoscopic or surgical correlation.

CONCLUSION

Ultrasound is a useful tool for the evaluation of inflammatory bowel disease and many other bowel diseases. Radiologists must become familiar with the full potential of ultrasound in the evaluation of the bowel in children because the need for alternative radiation-free imaging techniques continues to grow.

Early prediction of complex midgut volvulus in neonates and infants

INTRODUCTION

Prognosis of midgut volvulus in neonates and infants younger than 1 year remains poor, as diagnostic findings may not be apparent until gut infarction had occurred. To characterize factors that help to predict complex midgut volvulus early was aim of this study.

METHODS

Institutionally approved retrospective analysis of all children younger than 1 year treated for midgut volvulus at the author's center from January 2002 to December 2011. Medical history, symptoms, laboratory and radiologic findings as well as sequelae of midgut volvulus were evaluated.

RESULTS

In 10 years, 37 children fulfilled the inclusion criteria. Of these, 43% developed complications, and mortality rate was 16%. In 30% of the patients, the only clinical sign was a sudden worsening of the general condition and abdominal distension (complex 19% vs. simple 38%). In one child with simple midgut volvulus, all clinical, laboratory and radiologic signs were negative. CART analysis identified a base excess below -1.70 and preterm birth (<36 weeks) as the best discriminators of complex and simple midgut volvulus. A score >1pt (comprised of these two factors) was found in all children with complex and in 14% of simple midgut volvulus (p < 0.001). A positive score (>1pt) offers a sensitivity of 100% (81.7-100%), specificity of 85.7% (71.8-85.7%), a PPV of 84.2% (68.8-84.2%) and NPV 100% (83.8-100%).

DISCUSSION

The study shows that midgut volvulus has a substantial morbidity and mortality. Unfortunately, not all affected children get picked up by history, laboratory and imaging. However, the proposed score helps to identify subject with increased risk of complications. It has the potential to facilitate and accelerate diagnosis of complex midgut volvulus; ultimately, it might help to reduce morbidity and mortality.

Prenatal diagnosis and management of an intestinal volvulus with meconium ileus and peritonitis

Fetal intestinal volvulus is a rare but serious finding with a high risk of potential life threatening fetal complications. Delay in diagnosis or treatment can increase mortality and morbidity. We report a case of mild fetal bowel dilatation at 30 weeks of gestation and intestinal volvulus presented by the 'whirl-sign', intestinal perforation and meconium peritonitis with fetal ascites and polyhydramnios at 33 weeks of gestation. This case emphasizes the role of examination of the bowel in third trimester ultrasound and the importance of quick decision to delivery and interdisciplinary perinatal management at suspected fetal volvulus with bowel necrosis and intraabdominal bleeding.

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.

Diagnostic accuracy of ultrasound in determining the cause of bilious vomiting in neonates

Background

Plain radiography and contrast radiologic studies are traditionally the main options in evaluating neonates presenting with bilious vomiting. While ultrasonography (US) is more available, its diagnostic accuracy is in question.

Objectives

The purpose of this study is to determine the diagnostic accuracy of US in evaluating these patients with bilious vomiting.

Patients and Methods

All neonates with bilious vomiting or bilious nasogastric tube drainage presented to a children’s hospital in a 1.5-year period were included. US were performed in all patients. The results were compared with clinical and radiological data and the final diagnosis. We used chi-square and Fisher’s exact tests for analysis.

Results

The cause of bilious vomiting for 18 of the 23 included patients was surgical. All patients labeled as surgical candidates by US ended in surgery [positive predictive value (PPV) = 100%], while only 50% of the patients with inconclusive US were operated [negative predictive value (NPV) = 50%, Confidence Interval (CI) 95%: 29%-71%]. The sensitivity and specificity of US in diagnosing intestinal atresia (n = 9) was 89% [CI 95%: (68% - 100%)] and 100%. In cases with malrotation (n = 4) and midgut volvulus (n = 2), sonographic diagnosis was in concordance with final surgical diagnosis.

Conclusion

This study suggested that in cases in which US makes a certain diagnosis, its accuracy eliminates the need for further diagnostic tests, but if it is inconclusive, further radiological contrast studies should be tried to make the final diagnosis.

Malrotation beyond infancy

OBJECTIVE

The aim of this work was to study the various presentations of malrotation and management in patients older than 1 year.

MATERIALS AND METHODS

Medical records of patients operated on over the last 6 years who were older than 1 year with a diagnosis of intestinal malrotation were evaluated retrospectively. Data about age at presentation, sex, presenting symptoms, time to diagnosis, radiographic imaging performed, surgical intervention, complications, and postoperative follow-up were collected and evaluated.

RESULTS

The study population included 35 children and 3 adults. About three-fourths of pediatric patients were younger than 5 years, and about half of these presented in the second year of life. All patients who presented in the second year of life had a classical presentation of malrotation. Older patients presented more commonly with atypical symptoms. Of these, 5 older children were previously treated for suspected diagnosis of abdominal tuberculosis. Two patients were referred for acute pancreatitis and 1 for severe gastroesophageal reflux disease. Three adults presented with acute small intestinal obstruction and were diagnosed to have malrotation intraoperatively. Upper gastrointestinal contrast study was diagnostic of malrotation in all pediatric patients. Ultrasound and color Doppler study of the abdomen revealed abnormal relationship of the superior mesenteric artery and vein in about one-third of the patients. All patients underwent a standard Ladd procedure. Midgut volvulus was present in about one-fourth of patients. Forty percent of patients with atypical presentation had persistence of preoperative symptoms postoperatively. Two adults developed complications postoperatively. There was no mortality in the present study.

CONCLUSION

Malrotation should be suspected in all patients with varied acute or chronic abdominal symptoms, and the upper gastrointestinal contrast study should be conducted. If the existence of typical malrotation is confirmed, surgical correction is mandatory to avoid volvulus and intestinal obstruction independently of the patient's age.

Intestinal malrotation and catastrophic volvulus in infancy

BACKGROUND

Intestinal malrotation in the newborn is usually diagnosed after signs of intestinal obstruction, such as bilious emesis, and corrected with the Ladd procedure.

OBJECTIVES

The objective of this report is to describe the presentation of severe cases of midgut volvulus presenting in infancy, and to discuss the characteristics of these cases.

CASE REPORT

We performed a 7-year review at our institution and present two cases of catastrophic midgut volvulus presenting in the post-neonatal period, ending in death soon after the onset of symptoms. These two patients also had significant laboratory abnormalities compared to patients with more typical presentations resulting in favorable outcomes.

CONCLUSIONS

Although most cases of intestinal malrotation in infancy can be treated successfully, in some circumstances, patients' symptoms may not be detected early enough for effective treatment, and therefore may result in catastrophic midgut volvulus and death.

Three-dimensional ultrasonographic depiction of fetal abdominal blood vessels

OBJECTIVE

The purpose of this study was to identify fetal abdominal vasculature with 3-dimensional (3D) ultrasonography and to describe a systematic method for analysis of volume data sets.

METHODS

Three-dimensional volumes of the fetal abdomen were acquired prospectively in 30 patients between 15 and 34 weeks' gestation with color Doppler, high-definition (HD) flow, power Doppler, and B-flow imaging. All volumes were analyzed offline by 2 examiners separately. The feasibility of identifying the fetal abdominal blood vessels was analyzed. A standardized approach was applied to identify specific vessels by correlating the images with known anatomic landmarks.

RESULTS

The volumes were rotated into an anatomic orientation in the multiplanar mode, and then the vessels were identified in the following order: aorta (30 of 30), celiac trunk (29 of 30), superior mesenteric vein (28 of 30 and 26 of 30 for readers 1 and 2, respectively), superior mesenteric artery (29 of 30), left renal artery (25 of 30 and 26 of 30), right renal artery (27 of 30), common iliac arteries (30 of 30), umbilical arteries (26 of 27), external iliac arteries (20 of 22), umbilical vein (29 of 30), ductus venosus (30 of 30), hepatic vein (29 of 30), right portal vein (29 of 30), inferior vena cava (28 of 30), adrenal artery (2 of 30), hepatic artery (24 of 30 and 23 of 30), splenic artery (24 of 30 and 23 of 30), gastric artery (14 of 30 and 9 of 30), splenic vein (19 of 30 and 15 of 30), and renal vein (1 of 30). A step-by-step systematic approach to identify the abdominal vasculature from the ultrasonographic volume data set was developed.

CONCLUSIONS

Fetal abdominal vessels can be easily visualized when a systematic analysis is performed on 3D data set volumes. Visualization of the vessels was optimal when volumes were acquired with HD flow imaging.

Jack Barney Award. The changing spectrum of intestinal malrotation: diagnosis and management

BACKGROUND

Management of typical malrotation is universally accepted, but management of atypical malrotation is less well defined in both children and adults.

METHODS

Records of patients with malrotation diagnosed over 6 years were reviewed. Patients were grouped into typical or atypical based on ligament of Treitz location. Outcomes were evaluated using chi-square analysis.

RESULTS

Of 275 patients, 148 diagnosed with typical malrotation underwent Ladd's procedure. Based on symptoms, 91 of 127 patients with atypical malrotation were managed operatively. The remaining 36 patients were asymptomatic or had reflux symptoms only and were observed. Six of 36 subsequently required surgery due to symptoms, but 30 remain asymptomatic. No observed patients developed acute midgut volvulus. The overall postoperative complication rates were higher for atypical versus typical malrotation, 27% versus 16% (P < .05).

CONCLUSIONS

Close observation with repeat contrast study is an acceptable management option for patients with atypical malrotation who are asymptomatic or exhibit only reflux symptoms.