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Long B, Easter J, Koyfman A. High risk and low incidence diseases: Pediatric digestive volvulus. Am J Emerg Med 2024; 82:153-160. [PMID: 38908340 DOI: 10.1016/j.ajem.2024.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 06/10/2024] [Accepted: 06/12/2024] [Indexed: 06/24/2024] Open
Abstract
INTRODUCTION Pediatric digestive volvulus is a serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of pediatric digestive volvulus, including the presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION Pediatric digestive volvulus is a deadly condition most commonly associated with malrotation. It occurs when the stomach or small intestine twists on itself, resulting in ischemia and potentially strangulation with necrosis and perforation. Presentation differs based on the gastrointestinal (GI) segment affected, degree of twisting, and acuity of the volvulus. Gastric volvulus most commonly presents with retching with or without nonbilious emesis and epigastric distension with pain, while midgut volvulus typically presents with bilious emesis in infants. Patients with GI necrosis and perforation may present with hemodynamic compromise and peritonitis. If suspected, emergent consultation with the pediatric surgery specialist is necessary, and if this is not available, transfer to a center with a pediatric surgeon is recommended. Imaging includes plain radiography, ultrasound, or upper GI series, while treatment includes resuscitation, administration of antibiotics, and emergent surgical decompression and detorsion of the involved segments. CONCLUSION An understanding of pediatric digestive volvulus and its many potential mimics can assist emergency clinicians in diagnosing and managing this deadly disease.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Joshua Easter
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
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Calle-Toro JS, Elsingergy MM, Dennis R, Grassi D, Kidd M, Otero H, Andronikou S. Frequency of duodenal anatomical variants in neonatal and pediatric upper gastrointestinal tract series (UGI) and the influence of exam quality on diagnostic reporting of these. Clin Imaging 2022; 87:28-33. [DOI: 10.1016/j.clinimag.2022.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 04/05/2022] [Accepted: 04/08/2022] [Indexed: 11/29/2022]
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Intestinal malrotation causing chylous ascites in an adolescent: a case report. Int J Surg Case Rep 2020; 77:894-898. [PMID: 33395919 PMCID: PMC7732965 DOI: 10.1016/j.ijscr.2020.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 11/30/2020] [Accepted: 12/01/2020] [Indexed: 11/21/2022] Open
Abstract
Chylous ascites due to intestinal malrotation is a rare occurrence, especially in adolescent and adult patients. Chylous ascites due to intestinal malrotation typically occurs early in life with painless distension of the abdomen. Our case is a male adolescent who presented with abdominal pain and a history of congenital hernia repair. Ladd’s procedure was successfully performed in our case with no complications.
Introduction Intestinal malrotation is a rare etiology of chylous ascites in adolescents. Chylous ascites is caused by lymphatic system disarrangement, which can result in an anomalous build-up of a lymphatic fluid rich in lipid, namely chyle in the peritoneal cavity. Presentation of case We present a case of a 16-year-old Saudi Arabian male who came to the emergency department with right upper quadrant pain associated with difficulty in passing stool for one day and a history of congenital diaphragmatic hernia (CDH) repair at the age of 4 months. Free fluid in the abdomen was noticed in the bedside ultrasound. Abdominopelvic computed tomography revealed dilated small bowel loops and a whirl sign of the mesentery, which indicated intestinal torsion. The patient was treated using Ladd’s procedure, and a large volume of chylous fluid was removed from the abdomen. Postoperatively, the abdominal drain revealed no chyle, and the patient was followed-up as an outpatient at which point, he reported no abdominal pain. Discussion Intestinal malrotation is more commonly reported in children and associated with congenital chylous ascites. Chylous ascites by itself is a rare occurrence, and very few cases attribute it to intestinal malrotation in adults. Surgical management with Ladd’s procedure is a well-documented surgery in pediatric patients, and yet it was successfully performed in our adolescent patient. Conclusion Surgical management of chylous ascites secondary to intestinal malrotation in an adolescent, which is considered novel in this age group, including peritoneal lavage of chyle, resulted in favorable outcomes.
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Yassin S, Stoica I, Muntean A, Byrne A, Sweeney B. Chronic midgut volvulus - A challenging diagnosis. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2020. [DOI: 10.1016/j.epsc.2020.101676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Nwokoro CC, Emmanuel EA, Olatunji AA, Salami BA, Amosu LO, Ogundele IO. Malrotation of the midgut associated with horseshoe kidney presenting as gastric outlet obstruction in a 15-year-old boy. Afr J Paediatr Surg 2020; 17:122-126. [PMID: 33342849 PMCID: PMC8051629 DOI: 10.4103/ajps.ajps_92_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Malrotation occurs in approximately 1 in 500 live births. However, the true incidence of malrotation is unknown since many asymptomatic patients fail to present. Approximately 90% of patients with malrotation are diagnosed within the 1st year of life. Eighty per cent of them are diagnosed within the 1st month of life. Nevertheless, there are recent reports of manifestations later in life both as emergency conditions and more chronic gastrointestinal symptoms. The relationship between malrotation and horseshoe kidney has not been fully understood, but few case reports have highlighted their occurrence in the same patient. The mode of presentation of this case and its association with a horseshoe kidney is the reason for this report. This was a case of malrotation associated with horseshoe kidney. He had exploratory laparotomy and Ladd's procedure. Malrotation is associated with horseshoe kidney which presented as gastric outlet obstruction. He responded well to treatment after Ladd's procedure.
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Affiliation(s)
- Chigbundu Collins Nwokoro
- Department of Surgery, Paedaitric Surgery Unit, Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State, Nigeria
| | - E A Emmanuel
- Department of Anaesthesia and Intensive Care, Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State, Nigeria
| | - A A Olatunji
- Department of Radiology, Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State, Nigeria
| | - B A Salami
- Department of Surgery, Paedaitric Surgery Unit, Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State, Nigeria
| | - L O Amosu
- Department of Surgery, Paedaitric Surgery Unit, Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State, Nigeria
| | - I O Ogundele
- Department of Surgery, Paedaitric Surgery Unit, Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State, Nigeria
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Kim JY. Imaging Findings of Gastrointestinal Emergency in Infants and Young Children. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2020; 81:794-805. [PMID: 36238180 PMCID: PMC9432212 DOI: 10.3348/jksr.2020.81.4.794] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/09/2020] [Accepted: 07/20/2020] [Indexed: 11/15/2022]
Abstract
급성 복증(acute abdomen)은 갑자기 발생하는 심한 복부 통증으로 즉각적인 수술적 치료를 필요로 할 수도 있는 상태를 말한다. 소아 환자의 급성 복증의 원인은 다양하며, 수술적 치료를 해야 하는 질환부터 투약 치료를 받아야 하거나 임상적 관찰 만을 요하는 질환까지 다양하게 분류될 수 있다. 이러한 급성 복증의 환자에서 영상 검사의 역할은 가능하다면 복통의 원인이 되는 질환을 밝혀서 수술적 치료를 해야 하는 환자와 투약 치료를 해야 하는 환자를 구분해 주는 것이다. 장중첩증과 충수돌기염이 소아 환자에서 수술적 치료를 필요로 하는 급성 복증의 가장 흔한 원인 질환이므로, 급성 복통을 호소하는 영아에서는 장중첩증을, 좀 더 나이가 많은 소아에서는 충수돌기염을 영상 검사를 이용해 배제해 주는 것이 중요하다. 이 논문에서는 영유아 환자의 급성 복통을 유발할 수 있는 질환 중 특징적 영상 소견을 보이는 장중첩증, 충수돌기염, 중장 염전, 메켈 게실 및 중복낭종에 대해 소개하고자 한다
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Affiliation(s)
- Ji Young Kim
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Pediatric ileocolic intussusception: new observations and unexpected implications. Pediatr Radiol 2019; 49:76-81. [PMID: 30232533 DOI: 10.1007/s00247-018-4259-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 07/23/2018] [Accepted: 09/03/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Ileocolic intussusception occurs when the terminal ileum "telescopes" into the colon. We observed that ileocolic intussusception lengths are similar regardless of location in the colon. OBJECTIVE To examine the uniformity of ileocolic intussusception length and its relationship to colon location, symptom duration and reducibility. MATERIALS AND METHODS We retrospectively reviewed ultrasound-diagnosed pediatric ileocolic intussusceptions initially treated with pneumatic reduction at the Mayo Clinic or Texas Children's Hospital. We recorded demographic, imaging and surgical findings including age, gender, symptom duration, location of the ileocolic intussusception, reducibility with air enema and, if fluoroscopically irreducible, surgical findings. RESULTS We identified 119 ileocolic intussusceptions (64% boys), with 81% in the right colon. There was no significant relationship between ileocolic intussusception length and colon location (P=0.15), nor ileocolic intussusception length and symptom duration (P=0.36). Ileocolic intussusceptions were more distal with increasing symptom duration (P=0.016). Successful reductions were unrelated to symptom duration (P=0.84) but were more likely with proximal versus distal locations (P=0.02). CONCLUSION Ileocolic intussusception lengths are relatively uniform regardless of location along the course of the colon where they present. Our findings suggest that most of the apparent distal propagation of ileocolic intussusceptions is not caused by increasing telescoping of small bowel across the ileocecal valve but rather by foreshortening of the right colon. This implies poor cecal fixation and confirms fluoroscopic and surgical observations of cecal displacement from the right lower quadrant with ileocolic intussusceptions. The movement of the leading edge of the ileocolic intussusception during reduction is first due to "relocating" the cecum into the right lower quadrant after which the reduction of small bowel back across the ileocecal valve then occurs.
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Diagnostic Value of Ultrasound and Gastrointestinal Series Findings in Detection of Pediatric Intestinal Malrotation. IRANIAN JOURNAL OF RADIOLOGY 2018. [DOI: 10.5812/iranjradiol.15089] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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An unusual cause of duodenal obstruction in adults. Arab J Gastroenterol 2015; 16:63-5. [PMID: 25910574 DOI: 10.1016/j.ajg.2015.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 05/20/2014] [Accepted: 03/16/2015] [Indexed: 12/26/2022]
Abstract
BACKGROUND Intestinal malrotation refers to a spectrum of anomalies of midgut rotation and fixation at various stages during early embryonic development. In adults, malrotation manifests itself mainly in chronic non-specific abdominal complaints and may therefore be easily misdiagnosed beyond infancy. CASE PRESENTATION We present a case of an 82-year-old Caucasian man with vomiting and abdominal pain owing to malrotation complicated by duodenal obstruction and intestinal ischaemia confirmed by radiologic evaluation and autopsy report. CONCLUSION Although intestinal malrotation is generally discovered near birth, our case demonstrates that physicians should consider this diagnosis at advanced age as well. In addition, particularly radiologic findings are supportive in diagnosing malrotation.
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Patel RV, Jackson P, Zani A, De Coppi P. Laparoscopic management of midgut malrotation and tuberculous peritonitis in an adolescent boy. BMJ Case Rep 2014; 2014:bcr-2013-200714. [PMID: 24969067 PMCID: PMC4078532 DOI: 10.1136/bcr-2013-200714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
An unusual case of miliary plastic peritonitis associated with midgut malrotation in an adolescent in whom various diagnostic investigations, medical management and staged initial laparoscopic diagnostic followed by therapeutic procedure was curative have been presented. Tuberculous miliary plastic peritonitis causes dense adhesions between bowel loops and prevents midgut volvulus in a pre-existing malrotation. Diagnosis can be a challenge and threshold for diagnostic laparoscopy should be low. Interval correction of malrotation by laparoscopy after complete resolution of tuberculosis is easy, safe and effective, and cosmetically more pleasing. Midgut malrotation is a congenital anomaly referring to either lack of or incomplete rotation of fetal axis around the axis of superior mesenteric artery during fetal development. Most patients present with bilious vomiting in the first month of life because of duodenal obstruction or a volvulus. This is an unusual case of midgut malrotation in association with tuberculous peritonitis in an adolescent boy.
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Affiliation(s)
- Ramnik V Patel
- Department of Paediatric Urology, University College London Hospitals NHS Foundation Trust, London, UK
- Department of Paediatric Urology, Great Ormond Street Children's Hospital NHS Trust, London, UK
| | - Paul Jackson
- Department of Paediatric Surgery, GOSH and ICH, London, UK
| | - Augusto Zani
- Department of Paediatric Surgery, GOSH and ICH, London, UK
| | - Paolo De Coppi
- Department of Paediatric Surgery, GOSH and ICH, London, UK
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Khatami A, Mahdavi K, Karimi MA. Ultrasound as a feasible method for the assessment of malrotation. Pol J Radiol 2014; 79:112-6. [PMID: 24860630 PMCID: PMC4031226 DOI: 10.12659/pjr.890219] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 01/13/2014] [Indexed: 11/21/2022] Open
Abstract
Background In malrotation the position of third portion of duodenum (D3) is always intramesenteric. Demonstration of normal retromesenteric-retroperitoneal position of D3 on ultrasound (US) can rule out malrotation. The aim of this study was to evaluate the feasibility of US in demonstrating the retroperitoneal D3. Material/Methods Abdominal US study was done for various indications in 60 newborns and infants (mean age: 33 days [range: 4–100 days]; 56.7% male) by an expert pediatric radiologist. The position of D3 and its adjacent structures was evaluated in axial and longitudinal planes by linear and curved transducers. Results A normal retromesenteric-retroperitoneal D3 located between the superior mesenteric artery and the aorta was seen on US in all patients, including those with extensive gas in the bowel. The mean time of D3 observation was 47.8 s (10–180 s). Ultrasound was also capable of demonstrating D3 structure, diameter, content, adjacent structures, relative position of the superior mesenteric artery and vein. Conclusions Ultrasound is a simple, fast and highly accurate tool to confirm the retroperitoneal position of D3. Ultrasound can be used as a screening method for malrotation eliminating the need for unnecessary barium studies.
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Affiliation(s)
- Alireza Khatami
- Department of Radiology, Mofid Children's Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Kiarash Mahdavi
- Department of Radiology, Mofid Children's Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Ali Karimi
- Department of Radiology, Mofid Children's Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Haak BW, Bodewitz ST, Kuijper CF, de Widt-Levert LM. Intestinal malrotation and volvulus in adult life. Int J Surg Case Rep 2014; 5:259-61. [PMID: 24709622 DOI: 10.1016/j.ijscr.2014.02.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 02/25/2014] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Midgut volvulus due to intestinal malrotation is a rare cause of intestinal obstruction when occurring in adult life. This paper documents the difficulties in reaching an early diagnosis. PRESENTATION OF CASE We describe the case of an 85-year-old man with non-specific abdominal complaints for 20 years, who presented with sudden onset central abdominal pain. An acute median laparotomy under general anaesthesia was performed during which a 360° clockwise rotation of the small bowel around the mesenteric pedicle of the superior mesenteric artery and vein was found. DISCUSSION Malrotation is considered any deviation of the normal rotation of the midgut in embryological development, causing intermittent episodes of gastrointestinal obstruction or acute events of midgut volvulus. Although mainly a paediatric diagnosis, some cases do present in adult life. Radiologic investigations include: upper gastrointestinal contrast studies, Doppler sonography and a contrast enhanced CT of the abdomen. If a true malrotation is diagnosed or found by coincidence, a Ladd's procedure is advised, even if the patient is asymptomatic. There is no proven surgical strategy for preventing the recurrence of small bowel volvulus in case of malfixation of the midgut. CONCLUSION Non-specific recurrent abdominal complaints in adults of any age should raise suspicion of the possibility of a midgut malrotation or malfixation with or without intermittent volvulus. This case highlights the importance of diagnosis in an early stage.
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Affiliation(s)
- Bastiaan W Haak
- Department of Surgery, Waterland Hospital, Waterlandlaan 250, 1441 RN Purmerend, The Netherlands.
| | - Sander T Bodewitz
- Department of Radiology, Waterland Hospital, Waterlandlaan 250, 1441 RN Purmerend, The Netherlands
| | - Caroline F Kuijper
- Department of Pediatric Surgery, Emma Children's Hospital-AMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Louise M de Widt-Levert
- Department of Surgery, Waterland Hospital, Waterlandlaan 250, 1441 RN Purmerend, The Netherlands
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Oelhafen K, Shayota BJ, Muhleman M, Klaassen Z, Shoja MM, Tubbs RS, Loukas M. Peritoneal Bands: A Review of Anatomical Distribution and Clinical Implications. Am Surg 2012. [DOI: 10.1177/000313481207800424] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The complexity of embryological development of the gastrointestinal tract and mesentery provides a platform for the formation of a wide variety of variant veils, folds, and membranes, collectively termed peritoneal bands. These structures, which represent anatomically unabsorbed portions of the omentum and mesentery, although often benign, have the potential to cause clinically significant manifestations in both the neonate and adult. Although these deviant structures may be identified over a broad range of the abdominal cavity, they are most commonly identified in the regions of the duodenum, duodenojejunal flexure, ileocecal junction, and ascending colon. As a result of the diverse location of these variant structures, clinical manifestations are highly variable, ranging from acute presentations of intestinal necrosis as a result of strangulated midgut volvulus to chronic, vague abdominal pain. This article seeks to highlight the importance of a thorough anatomical understanding of the distribution of the various abnormal peritoneal folds, bands, and ligaments, which may result from aberrations in embryonic gastrointestinal development and their respective clinical implications. Moreover, to advance the knowledge of peritoneal bands, this article discusses the appropriate diagnostic studies and treatment interventions required for these variant structures.
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Affiliation(s)
- Kim Oelhafen
- St. George's University School of Medicine, St. George's, Grenada, West Indies
| | - Brian J. Shayota
- St. George's University School of Medicine, St. George's, Grenada, West Indies
| | - Mitchel Muhleman
- St. George's University School of Medicine, St. George's, Grenada, West Indies
| | - Zachary Klaassen
- St. George's University School of Medicine, St. George's, Grenada, West Indies
- Department of Surgery, Saint Barnabas Medical Center, Livingston, New Jersey
| | | | - R. Shane Tubbs
- Pediatric Neurosurgery, Children's Hospital, Birmingham, Alabama
| | - Marios Loukas
- St. George's University School of Medicine, St. George's, Grenada, West Indies
- Department of Anatomy, Medical School Varmia and Mazuria, Olsztyn, Poland
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Valsky DV, Cohen SM, Hamani Y, Lipschuetz M, Yagel S, Esh-Broder E. Whirlpool sign in the diagnosis of adnexal torsion with atypical clinical presentation. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2009; 34:239-242. [PMID: 19644943 DOI: 10.1002/uog.7310] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- D V Valsky
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Centers, Mt. Scopus, Jerusalem, Israel.
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Ren PT, Lu BC. Intestinal malrotation associated with colon cancer in an adult: report of a case. Surg Today 2009; 39:624-7. [PMID: 19562454 DOI: 10.1007/s00595-008-3913-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2008] [Accepted: 10/30/2008] [Indexed: 12/12/2022]
Abstract
Intestinal malrotation is a congenital anomaly of intestinal rotation and fixation that generally becomes symptomatic during the neonatal period. However, it rarely occurs in adulthood, and synchronous colon cancer is even rarer. This report presents the case of a 45-year old man who suffered from intestinal malrotation associated with colon cancer.
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Affiliation(s)
- Pei-Tu Ren
- Department of General Surgery, Shaoxing People's Hospital, Shaoxing, 312000, Zhejiang Province, PR China
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Abstract
Hepatobiliary scintigraphy is primarily used to diagnose acute and chronic biliary tract disorders. However, its potential role in diagnosing unsuspected extrahepatic pathology is not well described. We present 2 adult patients with chronic abdominal pain who underwent hepatobiliary scintigraphy for evaluation of cystic duct patency. In both cases, the proximal small bowel was located on the right side of the abdomen, which suggested the diagnosis of malrotation. Retrospective review of abdominal CT scan, upper gastrointestinal series, and subsequent laparotomy confirmed malrotation. The diagnosis of malrotation in both these patients was first suggested on hepatobiliary scintigraphy, which significantly impacted their subsequent management.
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Penco JMM, Murillo JC, Hernández A, De La Calle Pato U, Masjoan DF, Aceituno FR. Anomalies of intestinal rotation and fixation: consequences of late diagnosis beyond two years of age. Pediatr Surg Int 2007; 23:723-30. [PMID: 17594104 DOI: 10.1007/s00383-007-1972-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/29/2007] [Indexed: 01/16/2023]
Abstract
The malrotation and no well fixation anomalies of the digestive tract is also frequent in older child, young and adult, with characteristic and specific clinical presentation. Actually, the diagnostic and treatment seem to be late, after suffering prolonged symptoms and/or in emergency. We present nine cases of anomalies in the embryonic development of the digestive tract which were diagnosed and treated in infants or young, all above 2 years old. Eight cases were of more or less complete intestinal malrotation; one of them was a complete malrotation with an intrinsic duodenal stenosis associated (no bands of Ladd) and another one was a right paramesocolic hernia, always accompanied by malrotation. The association with other extra-digestive anomalies, especially urological, was 70%. The predominant symptom was intermittent abdominal pain (IAP)-80%-sometimes accompanied by vomiting (35%) and episodes of diarrhoea (25%). In all the cases, while the clinical background was early, diagnosis was late. Indeed, in 60% of the cases diagnosis was made intra-operatively in emergency surgical interventions. The imaging procedures employed were scanning and Doppler ultrasound, CT scan, and contrast gastrointestinal series (GIS). Up to 30% of errors in interpretation occurred, although they were eventually corrected with other tests. The most reliable diagnostic procedures were GIS and CT scan with contrast, although partial interpretation errors occurred with the latter procedure. Surgery was essential in 80% of the pre-operative cases, and in another two it was required as a preventative measure. Post-operatively, there was notable persistence of SBS in the cases of intestinal necrosis, and of other lesser symptoms in the rest. We conclude that: intestinal malrotations and malfixations are still being diagnosed very late, with serious systemic consequences such as intestinal obstructions or necroses, and prolonged clinical suffering. This could all be avoided if more attention were paid to the digestive symptoms associated with IAP, and to subocclusion or other abdominal phenomena (distension,...), together with, in the case of doubt about the findings with the previous procedures, the opportune imaging tests (e.g., abdominal Doppler ultrasound, CT scan with contrast, and barium GIS). Unlike other authors, we consider that the morbidity/mortality associated with cases of late diagnosis of these anomalies is high, and calls for earlier surgical treatment.
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Affiliation(s)
- J M Moran Penco
- University Children's Hospitals of Seville and Badajoz, The San Francisco Surgical Clinic of Cáceres, Faculty of Medicine, University of Extremadura, Caceres, Spain.
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Tawil MI. Pediatric Emergencies: Non-traumatic Abdominal Emergencies. Emerg Radiol 2007. [DOI: 10.1007/978-3-540-68908-9_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Applegate KE, Anderson JM, Klatte EC. Intestinal malrotation in children: a problem-solving approach to the upper gastrointestinal series. Radiographics 2006; 26:1485-500. [PMID: 16973777 DOI: 10.1148/rg.265055167] [Citation(s) in RCA: 119] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Intestinal malrotation, which is defined by a congenital abnormal position of the duodenojejunal junction, may lead to midgut volvulus, a potentially life-threatening complication. An evaluation for malrotation is part of every upper gastrointestinal (GI) tract examination in pediatric patients, particularly neonates and infants. Although the diagnosis of malrotation is often straightforward, the imaging features in approximately 15% of upper GI tract examinations are equivocal and lead to a false-positive or false-negative interpretation. The clinical manifestations and upper GI tract findings of malrotation in older children and adults are less specific than are those in younger patients, and for this reason diagnosis of the condition may be more difficult. Successful differentiation between a normal variant and malrotation requires the use of optimal techniques in acquiring and interpreting the upper GI series. Familiarity with the upper GI series appearance of both normal and abnormal anatomic variants allows the radiologist to increase both diagnostic accuracy and confidence in the diagnosis of malrotation.
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Affiliation(s)
- Kimberly E Applegate
- Department of Radiology, Riley Hospital for Children, 702 Barnhill Dr, Room 1053B, Indianapolis, IN 46202, USA.
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Affiliation(s)
- Monica Epelman
- Department of Diagnostic Imaging, the Hospital for Sick Children, Toronto, Ontario, Canada.
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Matzke GM, Dozois EJ, Larson DW, Moir CR. Surgical management of intestinal malrotation in adults: comparative results for open and laparoscopic Ladd procedures. Surg Endosc 2005; 19:1416-9. [PMID: 16151680 DOI: 10.1007/s00464-004-8249-7] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2005] [Accepted: 03/28/2005] [Indexed: 11/28/2022]
Abstract
BACKGROUND This study aimed to characterize the clinical features of intestinal malrotation in adults, and to compare the results for the open and laparoscopic Ladd procedures. METHODS Between 1984 and 2003, 21 adult patients with a mean age of 36 years (range, 14-89 years) were surgically treated for intestinal malrotation. The clinical data collected included age, gender, presenting symptoms, diagnostic tests, type of operation, operative time, narcotic requirement, time to oral intake, length of hospital stay, and outcome. The groups (open vs laparoscopic) were comparatively analyzed using two-sample t-tests and Wilcoxon rank sum tests. RESULTS The two groups were similar in terms of age, clinical presentation, and diagnostic tests performed. The most common presenting symptoms were chronic abdominal pain, nausea, and repeated vomiting. Upper gastrointestinal barium studies (UGI/SBFT) were diagnostic for all patients with malrotation as compared with computed tomography (CT) scanning, which was falsely negative in 25% of patients. A total of 21 patients underwent the Ladd procedure, either open (n = 10) or laparoscopic (n = 11). Three laparoscopic procedures were converted to open. Overall, the laparoscopic group resumed oral intake earlier than the open group (1.8 vs 2.7 days; p = 0.092), had a shorter hospital stay (4.0 vs. 6.1 days; p = 0.050), and required less intravenous narcotics on postoperative day 1 (4.9 vs 48.5 mg; p = 0.002). The laparoscopic group underwent a longer operation (194 vs 143 min; p = 0.053). Sixteen of eighteen patients available for follow-up reported complete resolution of symptoms, 2 felt greatly improved. No patient required a second operation related to volvulus or recurrent symptoms. CONCLUSIONS The laparoscopic Ladd procedure is feasible, safe, and as effective as the standard open Ladd procedure for the treatment of adults who have intestinal malrotation without midgut volvulus. Patients also benefit from this minimally invasive approach, as manifested by an earlier oral intake, a decreased need for intravenous narcotics, and an earlier discharge from the hospital.
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Affiliation(s)
- G M Matzke
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic and Mayo Foundation, Rochester, MN 55905, USA
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Aidlen J, Anupindi SA, Jaramillo D, Doody DP. Malrotation with midgut volvulus: CT findings of bowel infarction. Pediatr Radiol 2005; 35:529-31. [PMID: 15536561 DOI: 10.1007/s00247-004-1355-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2004] [Revised: 09/17/2004] [Accepted: 09/23/2004] [Indexed: 02/04/2023]
Abstract
Midgut volvulus, the most common serious complication of malrotation, can be diagnosed using conventional contrast fluoroscopy, US or CT. CT is a quick and comprehensive examination in the evaluation of complex acute abdominal pathology in children. Contrast-enhanced CT can readily help the radiologist recognize perfusion abnormalities of the bowel, which is vital for reducing morbidity and mortality in affected children. Our case emphasizes and demonstrates additional CT features of bowel infarction in a child with a proven malrotation with midgut volvulus.
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Affiliation(s)
- Jeremy Aidlen
- Department of Surgery, University of Massachusetts Medical Center, Worchester, MA, USA
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Imamoglu M, Cay A, Sarihan H, Sen Y. Rare clinical presentation mode of intestinal malrotation after neonatal period: Malabsorption-like symptoms due to chronic midgut volvulus. Pediatr Int 2004; 46:167-70. [PMID: 15056243 DOI: 10.1046/j.1442-200x.2004.01859.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Many different and non-specific clinic presentation modes of malrotation anomalies (MA) have been reported after neonatal period. The authors describe four children with MA presented with malabsorption-like clinical features. METHODS Three children aged from 8 months to 7 years, with a history of long-standing diarrhea and failure to thrive attributed to malabsorption, were referred to Department of Pediatric Surgery, for evaluation of suspected MA. Another patient, a 10-year-old boy who was treated for malabsorption for 6 years, presented with acute duodenal obstruction findings. The duration of symptoms averaged 35 months, ranging 8 months to 6 years. All patients had undergone extensive evaluation and empiric trials of different formulas with no improvement in their symptoms. One underwent jejunal biopsy. RESULTS Primary presentation complaints were chronic diarrhea and failure to thrive in three patients. Their histories revealed chronic (in one) and intermittent colicky (in two) abdominal pain, and intermittent nonbilious vomiting (in three). The remaining patient presented with acute illness, with chronic diarrhea, failure to thrive, and intermittent abdominal pain and vomiting on his history. They were below 30th percentile according to body weight and height. Laboratory studies revealed hypoproteinemia, hypoalbunemia, raised liver function tests, and anemia in all patients. The patient who presented acutely had double-bubble sign on the plain abdominal film obtained at admission. In the other three, plain films obtained during an attack of abdominal pain and/or vomiting revealed findings of partial intestinal obstruction. The diagnosis was confirmed by upper gastrointestinal series. At their laparotomy, a classical type of malrotation with circumstantial evidence of chronic volvulus was noted. All patients had normal laboratory values between postoperative 3 and 5 weeks, and they were up to 30th percentile at the end of the 6 months. CONCLUSIONS Malrotation anomalies should be included in the differential diagnosis in a child presented with malabsorption-like clinical features.
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Affiliation(s)
- Mustafa Imamoglu
- Department of Pediatric Surgery, Karadeniz Technical University, Faculty of Medicine, Trabzon, Turkey.
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Pickhardt PJ, Bhalla S. Intestinal malrotation in adolescents and adults: spectrum of clinical and imaging features. AJR Am J Roentgenol 2002; 179:1429-35. [PMID: 12438031 DOI: 10.2214/ajr.179.6.1791429] [Citation(s) in RCA: 122] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Perry J Pickhardt
- Department of Radiology, National Naval Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889-5600, USA
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Berrocal T, Lamas M, Gutieérrez J, Torres I, Prieto C, del Hoyo ML. Congenital anomalies of the small intestine, colon, and rectum. Radiographics 1999; 19:1219-36. [PMID: 10489177 DOI: 10.1148/radiographics.19.5.g99se041219] [Citation(s) in RCA: 97] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Congenital anomalies of the gastrointestinal tract are a significant cause of morbidity in children and, less frequently, in adults. These abnormalities include developmental obstructive defects of the small intestine, anomalies of the colon, anomalies of rotation and fixation, anorectal anomalies, and intestinal duplications. Neonates with complete high intestinal obstruction do not usually require further radiologic evaluation following radiography, whereas those with complete low obstruction should undergo a contrast material enema examination. An upper gastrointestinal series must be performed in all patients with incomplete intestinal obstruction because management is different in each case. In low intestinal obstruction, ultrasonography (US) may help differentiate between small bowel obstruction and colonic obstruction. In addition, US can help correctly identify meconium ileus and meconium peritonitis and is useful in the diagnosis of enteric duplication cysts. In malrotation and anorectal anomalies, computed tomography (CT) and magnetic resonance (MR) imaging can provide superb anatomic detail and added diagnostic specificity. Intestinal duplications manifest as an abdominal mass at radiography, contrast enema examination, or US. At CT, most duplications manifest as smoothly rounded, fluid-filled cysts or tubular structures with thin, slightly enhancing walls. At MR imaging, the intracystic fluid has heterogeneous signal intensity on T1-weighted images and homogeneous high signal intensity on T2-weighted images. Familiarity with these gastrointestinal abnormalities is essential for correct diagnosis and appropriate management.
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Affiliation(s)
- T Berrocal
- Servicio de Radiodiagnóstico, Hospital Infantil La Paz, Madrid, Spain
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Yeh WC, Wang HP, Chen C, Wang HH, Wu MS, Lin JT. Preoperative sonographic diagnosis of midgut malrotation with volvulus in adults: the "whirlpool" sign. JOURNAL OF CLINICAL ULTRASOUND : JCU 1999; 27:279-283. [PMID: 10355892 DOI: 10.1002/(sici)1097-0096(199906)27:5<279::aid-jcu8>3.0.co;2-g] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Midgut malrotation and volvulus, found mostly in children, are rare and difficult to diagnose preoperatively in adults. We report 2 cases in which a 68-year-old man and a 75-year-old woman presented with intermittent cramping abdominal pain, abdominal distention, and vomiting. Abdominal sonography demonstrated wrapping of the superior mesenteric vein and bowel loops around the superior mesenteric artery (the "whirlpool sign") in both patients. Abdominal CT revealed similar findings. The diagnoses of midgut volvulus and mesenteric malrotation were made, and the patients underwent laparotomy. The man was confirmed to have duodenojejunal malrotation and volvulus, and the woman had cecal volvulus. The whirlpool sign is valuable for the preoperative diagnosis of mesenteric vessel malrotation and midgut volvulus.
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Affiliation(s)
- W C Yeh
- Department of Internal Medicine, En Chu Kong Hospital, Taipei Hsien, Taiwan
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