Disorders of intestinal rotation and fixation ("malrotation")

Fluoroscopy in pediatric radiology: Review of current use and alternatives

Fluoroscopy has long been an essential imaging modality in pediatric radiology. However, concerns about radiation exposure in children and the need for on-site staff have led to a decline in its use and the exploration of alternative imaging techniques. Data from the Pediatric Health Information System and our institution show a decrease in fluoroscopic studies among pediatric inpatients, from 56,371 per year (2017-2020) to 46,973 per year (2020-2023). Alternative modalities such as endoscopy, ultrasound, and computed tomography demonstrate promise in assessing conditions of the respiratory, gastrointestinal, and urinary systems. Although fluoroscopy remains valuable in certain scenarios, these alternative imaging modalities offer advantages in terms of diagnostic accuracy, accessibility, costs, and reduced radiation exposure. However, the final choice of imaging technique should be based on careful consideration of the specific clinical context, patient factors, and available resources. In this review, we present institutional and national trends on the utilization of fluoroscopic studies over the past years, along with a side-by-side comparison of traditional fluoroscopic studies commonly performed in children and newer alternative modalities.

Midgut volvulus with complete malrotation in an infant: First case report from Somalia

INTRODUCTION

Malrotation is a congenital anomaly affecting small and large bowels, with 1 in 500 live births globally. It's often accompanied by bilious vomiting, which may occur with or without abdominal distension. Midgut volvulus is a major complication that can arise from malrotation, presenting a significant risk to life and requiring immediate surgical intervention. This is the first case report of midgut volvulus with complete malrotation in an infant from Somalia.

CASE PRESENTATION

Our case is a 40-day old term male presented with bilious vomiting and constipation for 5 days. He was resuscitated and underwent Color Doppler ultrasound of the abdomen that showed the whirlpool sign and reversal of superior mesenteric artery and superior mesenteric vein. Following the Ladd's procedure, he was discharged from the hospital, demonstrating effective feeding and the absence of vomiting.

DISCUSSION

Intestinal malrotation, a congenital anomaly affecting approximately 1 in 500 live births, carries a significant risk of midgut volvulus, a life-threatening surgical emergency. This report presents the first documented case of complete intestinal malrotation with midgut volvulus in an infant from Somalia, highlighting the challenges of diagnosis and management in resource-constrained settings. The case highlights the importance of accessible diagnostic tools and prompt surgical intervention.

CONCLUSION

This case highlights the importance of heightened awareness, sonographic expertise, and skilled surgical management of midgut volvulus with complete malrotation to improve outcomes, particularly in underserved regions where access to advanced pediatric care remains limited.

Performance of Prenatal Ultrasound Screening for the Relative Positioning of Mesenteric Vessels

OBJECTIVES

Abnormal relative positioning of the superior mesenteric artery (SMA) and vein (SMV) can lead to intestinal malrotation that predisposes to midgut volvulus. The aim of this study was to assess the prenatal ultrasound ability to visualize the relative position of SMA and SMV in normal pregnancies.

METHODS

Prospective cohort study performed in Montpellier University Hospital Centre, including 80 fetuses during routine 3rd trimester ultrasound scan. For each fetus included, the relative position of the vessels on an axial image was defined as SMV on the right, forward, or on the left of SMA. Doppler imaging was additionally used if necessary. Data were compared to the neonatal abdominal scans performed by pediatric radiologist.

RESULTS

The superior mesenteric vessels were identified in 79 fetuses. Prenatal findings showed a usual relative position of the vessels, that is, the vein on the right of the artery, in 96.2%. In 2 cases, the vein was strictly in front of the artery, and in 1 case, the vein was on the left side of the artery. Seventy-four neonates were examined and comparison with prenatal finding showed a perfect agreement (Kappa coefficient of 100%). An intestinal malrotation was postnatally diagnosed corresponding to the case where vein was on the left side of the artery.

CONCLUSION

This study showed that the relative position of the SMA and SMV could be assessed using ultrasound prenatal examination with a perfect agreement with postnatal findings. In case of abnormal vessels positioning more examinations should be promote including prenatal MRI and postnatal conventional radiologic examinations to confirm intestinal malrotation.

An unusual case of small bowel and sigmoid volvuli presenting with dyspnea

Intestinal volvulus is a pathological condition that can lead to bowel obstruction and intestinal ischemia, and is therefore potentially fatal in severe cases. Patients' symptoms are often nonspecific: volvulus most frequently presents as an acute abdomen, but vague symptoms such as abdominal pain and distension, nausea and vomiting are common. In this scenario, the gold standard for diagnosis is contrast-enhanced computed tomography, which allows a timely assessment. However, in this article we present a rare case of a small bowel volvulus associated with a sigmoid volvulus in which the patient presented to the emergency department with respiratory symptoms.

Validating the Cattell-Braasch maneuver with a case of inherent atypical malrotation of the bowel: a case report

BACKGROUND

Malrotation of the bowel due to imperfect embryologic development is a rare condition with a wide spectrum of resulting anatomical variations. Similar conditions are achieved in the adult by derotating the bowel via the Cattell-Braasch maneuver. However, possible preparational bias might compromise the resulting topography.

CASE PRESENTATION

We present a case of atypical malrotation of the bowel in a cadaver study using a 96-year-old Caucasian male specimen with incidental finding of the pathology post mortem with no known surgical intervention in the abdomen during his lifetime. We compare the topography and abdominal layers with the anatomy of a 98-year-old Caucasian female specimen where the Cattell-Braasch maneuver was used to revert the embryologic development.

CONCLUSIONS

Reverting the embryologic development in the adult via Cattell-Braasch maneuver enables to mirror inherent malrotation and reestablishes the position of the bowel prior to its rotation. The Cattell-Braasch maneuver is further validated in this study by showing that it is able to demonstrate essential layers for surgical interventions without damaging their integrity. Atypical malrotation unmasks those fascial border-like layers, which are often hidden due to adhesions and fusing of tissue during the usual embryologic development. Developmental defects present a chance to explore essential surgical layers that are otherwise masked by artifacts due to fusion of layers of connective tissue.

Left side appendiceal abscess in a patient with intestinal nonrotation: Case report

Intestinal nonrotation is the most common type of mid-gut anomaly where the small bowel predominantly occupies the right side of the peritoneal cavity, while the colon primarily resides on the left. The occurrence of acute appendicitis in mid-gut anomalies poses a serious diagnostic challenge due to unprecedented clinical and imaging features. Here we present a 20-year-old female who came to the hospital with left lower abdominal pain of 3 weeks duration, referred with a diagnosis of tubo-ovarian abscess. Further evaluation with an abdominopelvic CT scan revealed ileocecal junction in the left lower quadrant with a well-defined appendiceal abscess. The absence of a prior diagnosis of nonrotation, combined with the atypical presentation of pain, complicates the diagnosis of appendicitis. We emphasize the significance of considering left-sided appendicitis as a potential diagnosis for left-sided abdominal pain and recommend early cross-sectional imaging to prevent complications and improve surgical outcomes.

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.

Major surgical conditions of childhood and their lifelong implications: comprehensive review

BACKGROUND

In recent decades, the survival of children with congenital anomalies and paediatric cancer has improved dramatically such that there has been a steady shift towards understanding their lifelong health outcomes. Paediatric surgeons will actively manage such conditions in childhood and adolescence, however, adult surgeons must later care for these 'grown-ups' in adulthood. This article aims to highlight some of those rare disorders encountered by paediatric surgeons requiring long-term follow-up, their management in childhood and their survivorship impact, in order that the adult specialist may be better equipped with skills and knowledge to manage these patients into adulthood.

METHODS

A comprehensive literature review was performed to identify relevant publications. Research studies, review articles and guidelines were sought, focusing on the paediatric management and long-term outcomes of surgical conditions of childhood. The article has been written for adult surgeon readership.

RESULTS

This article describes the aforementioned conditions, their management in childhood and their lifelong implications, including: oesophageal atresia, tracheo-oesophageal fistula, malrotation, short bowel syndrome, duodenal atresia, gastroschisis, exomphalos, choledochal malformations, biliary atresia, Hirschsprung disease, anorectal malformations, congenital diaphragmatic hernia, congenital lung lesions and paediatric cancer.

CONCLUSION

The increasing survivorship of children affected by surgical conditions will translate into a growing population of adults with lifelong conditions and specialist healthcare needs. The importance of transition from childhood to adulthood is becoming realized. It is hoped that this timely review will enthuse the readership to offer care for such vulnerable patients, and to collaborate with paediatric surgeons in providing successful and seamless transitional care.

Notable Clinical Differences Between Neonatal and Post-Neonatal Intestinal Malrotation: A Multicenter Review in Southern Japan

BACKGROUND

Most cases of intestinal malrotation appear in neonates with bilious vomiting due to midgut volvulus, whereas in cases that develop beyond infancy, the initial symptoms vary. This study investigated the clinical features of these two populations and identified issues that should be considered in daily practice.

METHODS

A retrospective chart review was conducted from January 1, 2010, to December 31, 2022. Data on patients with intestinal malrotation were collected in an anonymized fashion from five pediatric surgical hub facilities in the Southern Kyushu and Okinawa areas of Japan.

RESULTS

Of the 80 subjects, 57 (71.3%) were neonates (Group N) and 23 (28.7%) were infants and schoolchildren (Group I). The frequencies of initial symptoms, such as abdominal distention (Group N: 19.3% vs. Group I: 13.0%), bilious vomiting (59.6% vs. 43.5%), and hematochezia (8.8% vs. 21.7%), were not skewed by the age of onset (p = 0.535, 0.087, and 0.141, respectively). Midgut volvulus was significantly more frequent in Group N (71.9% [41/57] vs. 34.8% [8/23]; p = 0.005), while the degree of torsion was greater in group I (median 360° [interquartile range: 180-360°] vs. 450° [360-540°]; p = 0.029). Although the bowel resection rate was equivalent (7.0% [4/57] vs. 4.3% [1/23]; p = 1.000), half of the patients in Group N presented with 180° torsion. The neonatal intestine has been highlighted as being more susceptible to ischemia than that in older children.

CONCLUSIONS

The incidence of midgut volvulus is higher in neonates than in older children. Even relatively mild torsion can cause ischemic bowel changes during the neonatal period.

LEVEL OF EVIDENCE

LEVEL III.

Quality and Diagnosis on the Lateral View of Pediatric Upper Gastro-Intestinal Series

BACKGROUND

The standard imaging technique for the diagnosis of intestinal malrotation remains the upper gastro-intestinal series (UGIS). The lateral view is promoted as important for making a diagnosis. For this, the lateral view should be of adequate quality, and radiologists must know the normal appearance as well as the appearance of duodenal variants, as misdiagnosis may lead to unnecessary surgery.

OBJECTIVE

We aimed to evaluate the quality, findings including the prevalence of the "descending staircase" configuration and its correspondence to a diagnosis of duodenum redundum.

MATERIALS AND METHODS

This was a retrospective study and was conducted in a large tertiary children's hospital in the United States. A retrospective review of UGI fluoroscopy exams in children aged ≤ 18 years between January and December 2018 was performed by a pediatric radiologist. First, the lateral view images/cine-loops were assessed independently, followed by the anteroposterior (AP) view. The studies which were designated to have an adequate lateral view were evaluated for configuration of the duodenum and recorded as: normal, abnormal, or normal variant. Also, the presence of a descending staircase configuration was correlated with an AP view for a diagnosis of duodenum redundum.

RESULTS

A total of 26 children (26%) (males:16; females:10) with age range 0 to 16 years had adequate lateral views during UGI exams for inclusion. Of the 26, 18 (69%) were reported as normal, 7 (27%) were reported as having a descending staircase and 1 (4%) was reported as abnormal. The AP view demonstrated 2 abnormal studies (1 malrotation and 1 non-rotation), 6 duodenum redundum and 18 normal exams. The one abnormal lateral duodenum was confirmed as a non-rotation on AP view; the second patient with an abnormal AP view had a normal appearance on the lateral view.

CONCLUSIONS

A total of 26% of UGI studies had adequate lateral views for interpretation. Of these, nearly a quarter (23%) demonstrated the descending stair-case sign corresponding to a diagnosis of duodenum redundum on the AP view. If the lateral view had been used alone, there would have been a missed diagnosis in one patient.

[Malrotation and Midgut Volvulus in Children: Diagnostic Approach, Imaging Findings, and Pitfalls]

Malrotation and midgut volvulus are surgical emergencies that commonly occur within the first month of life. The classic symptom is acute bilious vomiting, while nonspecific symptoms such as recurrent abdominal pain may be present in older children. Malrotation can be associated with duodenal obstruction caused by an abnormal peritoneal fibrous band or congenital anomalies, such as an annular pancreas or a preduodenal portal vein. Volvulus can lead to bowel ischemia and a life-threatening condition, thus prompt and accurate diagnosis is crucial. Diagnosis can be made through upper gastrointestinal series, ultrasonography, and CT, with ultrasonography being preferred as a screening tool due to its rapid and accurate diagnosis, without radiation exposure, in children. This pictorial essay discusses the key imaging findings and diagnostic approaches for malrotation and midgut volvulus, as well as diagnostic pitfalls based on actual cases.

IMPOWER: a national patient-generated registry for intestinal malrotation exploring diagnosis, treatment, and surgical outcomes

BACKGROUND

Intestinal malrotation is a rare congenital condition with potentially devastating consequences due to potential volvulus and massive intestinal necrosis. Diagnosis is often delayed and long-term symptoms following surgical correction are poorly characterized. We developed the Intestinal Malrotation Patient Outcomes and WEllness Registry (IMPOWER), a national patient-generated registry (PGR), to capture data related to presenting symptoms, testing, diagnosis, treatment, and follow-up of individuals diagnosed with malrotation. IMPOWER captures patient-reported information from adult patients and parents/caregivers of children diagnosed with malrotation at the time of enrollment and at ongoing 6-month intervals. We present baseline characteristics of patients enrolled during the first two months of the registry.

RESULTS

Within the first two months, 354 patients with malrotation enrolled in IMPOWER, and 191 (53.9%) completed all baseline assessments. Nearly 90% of the 119 pediatric participants and 37.7% of the 72 adult participants experienced symptoms prior to diagnosis. Vomiting was the predominant symptom for pediatric participants compared to abdominal pain in adults. Yellow bilious emesis was more commonly reported than green, and volvulus at diagnosis occurred in 70% of pediatric and 27% of adult participants. One-third of pediatric participants had a bowel resection as part of their initial surgical procedure, resulting in 23.4% with diagnosed short bowel syndrome. More than 60% of pediatric and 80% of adult registrants reported gastrointestinal symptoms that persisted throughout the first year following their initial operation. Approximately 25% of registrants reported visiting four or more gastroenterologists for management of ongoing symptoms.

CONCLUSIONS

Fewer than half of pediatric patients presented with the "classic" presentation of green bilious colored emesis. Yellow bilious emesis was more commonly reported, and chronic gastrointestinal symptoms (i.e., abdominal pain, reflux, constipation, diarrhea) and feeding intolerance were common following surgical procedures for malrotation. This novel PGR highlights the need for a multicenter prospective registry to characterize the natural history and develop consistent standards of care related to the diagnosis, treatment, and long-term care for patients with malrotation.

Left Side Appendicitis with Abscess Caused by Midgut Malrotation Mimicked by Complicated Diverticulitis of Sigmoid Colon: A Case Report

Midgut malrotation (MM) is a rare anatomical abnormality that complicates the diagnosis and management of acute abdominal pain. Moreover, appendicitis and diverticulitis of the sigmoid colon can be considered when there is pain in the lower left abdomen. The patient in this case report was an 86-year-old female who had continuous abdominal pain two days before the visit to the emergency room. Abdominopelvic computed tomography revealed MM, and uneven concentric wall thickening from the distal descending colon to the proximal sigmoid colon with surrounding fatty infiltration was confirmed in the left lower abdomen. Moreover, the possibility of left-sided appendicitis due to MM could not be excluded. The patient's abdominal pain increased next day. The surgery was performed laparoscopically, and the location of the appendix was reversed. The surgical findings revealed an abscess caused by perforation from inflammation of the proximal part of the appendix, and the sigmoid colon adhered mildly to the side immediately behind the abscess cavity. The base of the appendix was intact, and only an appendectomy was performed. Left-sided appendicitis due to MM was discriminated from the diverticulitis of the sigmoid colon. Diagnostic laparoscopic surgery through a physical examination based on the surgeon's experience is important.

Predictive factors of bowel resection for midgut volvulus based on an analysis of bi-center experiences in southern Japan

PURPOSE

Midgut volvulus is an urgent disease often occurring in neonates. This study clarified the clinical features of midgut volvulus and evaluated predictors to avoid bowel resection.

METHODS

This bi-center retrospective study enrolled 48 patients who underwent surgery for intestinal malrotation between 2010 and 2022. Patients' background characteristics and preoperative imaging findings were reviewed.

RESULTS

Midgut volvulus was recognized in 32 patients (66.7%), and 6 (12.5%) underwent bowel resection. Based on a receiver operating curve analysis of bowel resection, the cut-off value of the body weight at birth and at operation were 1984 g [area under the curve (AUC) 0.75, 95% confidence interval (CI) 0.52-0.99] and 2418 g (AUC 0.70, 95% CI 0.46-0.94), respectively. The cut-off value of intestinal torsion was 540° (AUC 0.76, 95% CI 0.57-0.95), and that of the time from the onset to the diagnosis was 12 h (AUC 0.85, 95% CI 0.72-0.98). For midgut volvulus with an intestinal torsion > 540°, the most sensitive preoperative imaging test was ultrasonography (75%) Patients with bloody stool tended to undergo bowel resection.

CONCLUSIONS

Patients with a low body weight and bloody stool should be confirmed to have whirlpool sign by ultrasonography and scheduled for surgery as soon as possible.

US for Evaluation of Acute Abdominal Conditions in Neonates

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

Incidental Discovery of Nonrotation in a Patient With Nonspecific Abdominal Pain: A Surgical Diagnostic Dilemma

Intestinal nonrotation is a subtype of malrotation occurring when the midgut fails to rotate before returning to the peritoneal cavity between weeks 8-10 of development. Though sometimes presenting as volvulus during the neonatal period, a subset of patients remains asymptomatic and are identified incidentally as adults. When patients with intestinal nonrotation present with abdominal symptoms, there exists a diagnostic dilemma for the treating surgeon. We present the case of a patient who presented with acute abdominal pain and vomiting, with radiographic findings of intestinal nonrotation and no other acute pathology. Symptoms spontaneously resolved with conservative management for likely etiology of viral gastroenteritis. At the one-month follow-up, the patient had no residual or recurrent symptoms, with no further interventions planned.

Midgut malrotation presenting with hyperemesis gravidarum: A case report

RATIONALE

Midgut malrotation is a rare congenital abnormality resulting from failure of complete intestinal rotation and subsequent fixation during early fetal development. There appeared to be no obvious symptoms in most patients, and a few patients may exhibit symptoms similar to hyperemesis gravidarum, such as nausea and vomiting. Here, we present a case of midgut malrotation presenting as hyperemesis gravidarum.

PATIENT CONCERNS

A 27-year-old woman with an intrauterine pregnancy of 27 + 6 weeks complained of severe nausea and vomiting for 2 weeks.

DIAGNOSIS

Magnetic resonance imaging showed obvious dilatation in the proximal part of the duodenum and gastric cavity and the absence of a duodenal path dorsal to the superior mesenteric artery, which was diagnosed as midgut malrotation.

INTERVENTIONS

Considering that the patient's vital signs were stable, without manifestation of peritonitis or the risks of surgery to the fetus, conservative treatment was adopted. Unfortunately, the fetus developed severe hydrocephalus at 32 weeks. The patient and her family decided to abandon the fetus, and a mid-trimester-induced abortion was performed.

OUTCOMES

The related symptoms completely disappeared after delivery, and the relevant examination after discharge also confirmed the presence of midgut malrotation without gastrointestinal discomfort within 1 year after delivery.

LESSONS

Midgut malrotation can be considered as a differential diagnosis of hyperemesis gravidarum. Conservative treatment under close monitoring is desirable in pregnant women diagnosed with midgut malrotation.

Therapeutic actions in a 2-month-old child with teratoma and duodenal malrotation accompaniment

Introduction

and importance: A mature mediastinal teratoma is a rare type of tumor that can contain fully developed tissues and it is usually considered benign, more common in female and may require surgical removal. The most common locations for teratomas are the tailbone (coccyx), ovaries, and testicles, but in this case, the teratoma was located in the mediastinum.

Case presentation

Furthermore, intestinal malrotation could potentially lead the patient to gastrointestinal (GI) obstruction and PO intolerance. Here, we present a 2-month-old patient with considerable manifestation of GI intolerance due to intestinal malrotaion accompanied by mature mediastinal teratoma.

Clinical discussion

An evaluation of malrotation should be part of every upper GI tract examination in pediatric patients, particularly newborns and infants.

Conclusion

Finally, in this case, surgical intervention could enhance both malrotation and mediastinal teratoma.

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A mature mediastinal teratoma is a rare type of tumor that can contain fully developed tissues.

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Benign, more common in female and may require surgical removal.

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Evaluation for malrotation should be part of every upper GI tract examination in pediatric patients.

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In this case, surgical intervention could enhance both malrotation and mediastinal teratoma.

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Finally, in this case, surgical intervention could enhance both malrotation and mediastinal teratoma.

Impact of gastrointestinal comorbidities in patients with right and left atrial isomerism

BACKGROUND AND AIM

Heterotaxy syndrome, being right atrial isomerism (RAI) or left atrial isomerism (LAI), often presents with Congenital Heart Disease (CHD). Intestinal abnormalities, including malrotation are common. We assessed the spectrum of gut abnormalities and their impact on medium-term outcome in a cohort of patients with fetal and postnatal diagnoses of heterotaxy syndrome.

METHODS

We reviewed the cardiology records of heterotaxy syndrome patients from two centres, regarding the presence of CHD, time for cardiac intervention, presence of gastrointestinal abnormalities, and type/time of surgery. A questionnaire about gastrointestinal status was sent to patients <18 years old. Kaplan-Meier curves were derived for survival data and freedom from intervention.

RESULTS

Data were included for 182 patients (49 RAI and 133 LAI) of 247 identified. Questionnaires were sent to 77 families and 47 replied. CHD was present in all RAI and 61.7% of LAI cases. Thirty-eight patients had abdominal surgery (20.9%), similar for RAI and LAI (20.4% versus 21%, p> 0.99): Ladd procedure in 17 (44.7%), non-Ladd in 12 (31.5%), and both procedures in 9 (23.7%). Ten-year freedom from Ladd procedure for all was 86% for the whole cohort (RAI = 87%; LAI = 85%, p = 0.98). Freedom from any gastrointestinal surgery at 10 years was 79% for the whole cohort (RAI = 77%; LAI = 80%, p = 0.54). Ten-year freedom from cardiac surgery was 31% for the whole cohort (RAI = 6%; LAI = 43%, p < 0.0001).

CONCLUSIONS

In our cohort, one in five patients required abdominal surgery, mostly in their first year of life, similar for RAI and LAI. Between 1 and 10 years of follow-up, the impact of gastrointestinal abnormalities on outcome was minimal. Medium term survival was related to CHD.

A curious adult case of small bowel volvulus with congenital malrotation

Intestinal volvulus is defined as a twisting of the bowel on its mesentery. It itself is a rare occurrence, with documented incidence of 1% as the cause of all small bowel obstruction, with further 0.82% of them being associated with intestinal malrotation. The classical radiographic feature described in literatures is the whirlpool sign. We herein report a rare presentation of congenital malrotation causing a small bowel obstruction in a 43-year-old man. The patient presented with acute abdominal pain and underwent an emergency laparotomy and resection of small and large bowel (total of 3 m with primary anastomosis), with an estimated 2.6 m of viable small bowel left. The patient had a prolonged recovery complicated by another relook operation, superior mesenteric vein thrombus and a high-output stoma with subsequent electrolyte derangements and acute kidney injury. He was discharged on Day 26 and had been seen in the outpatient department with good functionality.

Congenital intestinal malrotation with gastric wall defects causing extensive gut necrosis and short gut syndrome: A case report

BACKGROUND

Congenital intestinal malrotation (CIM) is a common malformation in neonates. Early diagnosis and surgical intervention can improve the prognosis. CIM combined with congenital gastric wall defect is a potentially fatal condition. We present a severe case of CIM with gastric wall defect causing extensive gut necrosis and short gut syndrome. After three operations, the neonate survived and subsequently showed normal growth and development during infancy.

CASE SUMMARY

A male neonate (age: 4 d) was hospitalized due to bloody stools and vomiting for 2 d, and abdominal distention for 1 d. Emergent exploratory laparotomy revealed black purplish discoloration of the bowel loops. Bowel alignment was abnormal with congestion and dilatation of the entire intestine, and clockwise mesentery volvulus (720°). The posterior wall of the gastric body near the greater curvature showed a defect in the muscularis layer (approximately 5.5 cm), and a circular perforation (approximately 3 cm diameter) at the center of this defect. Ladd’s procedure was performed and gastric wall defect was repaired. Third operation performed 53 d after birth revealed extensive adherence of small intestine and peritoneum, and adhesion angulated between many small intestinal loops. We performed intestinal adhesiolysis, resection of necrotic intestine, and small bowel anastomosis.

CONCLUSION

This case highlights that prolonged medical treatment may help improve intestinal salvage after surgical removal of necrotic intestines, and improve patient prognosis.

Protective Effects of Hydrogen-Rich Saline on Experimental Intestinal Volvulus in Rats

BACKGROUND

Intestinal volvulus can cause morbidity and mortality. Surgical reduction, on the other hand, could result in ischemia-reperfusion (I/R) injury. Hydrogen rich saline solution (HRSS neutralizes free radicals in the body. This study aimed to investigate the effects of HRSS in I/R injury in experimental intestinal volvulus in rats.

METHODS

Thirty rats were randomly allocated into 5 groups. All procedures were done under general anesthesia and sterile conditions in each animal. Five ml/kg of saline and HRSS were administered intraperitoneally (ip) in Sham (Group 1) and HRSS (Group 2) groups, respectively. Groups 3, 4, and 5 constituted the study groups in which volvulus was created in a 5-cm- long ileal segment 2 cm proximal to the ileocecal valve. After 2 hours the volvuli were reduced and following 2 hours of reperfusion, these segments were removed. In volvulus-I/R group (Group 3) no additional procedure was done. HRSS was administered shortly before reperfusion (reduction of the volvulus) in Treatment I (Group 4) and 1 h before experimental volvulus in Treatment II (Group 5) groups. Blood and intestinal tissue samples were obtained from all rats at the 4th hour. Both tissue and blood total oxidant (TOS) and antioxidant status (TAS) levels were determined and tissue histomorphologies were studied. Oxidative stress indices (TOS ÷ TAS) (OSI) were calculated.

RESULTS

Tissue TOS and OSI levels and histomorphological injury scores were statistically lower in treatment groups than I/R group, whereas blood TOS and OSI levels were similar between the groups.

CONCLUSIONS

This study provides biochemical and histomorphological evidence that HRSS prevents intestinal damage in I/R injury caused by volvulus.

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

Midgut volvulus in association with malrotation is a pediatric surgical emergency. Prompt and accurate diagnosis is necessary to avoid bowel ischemia and necrosis, thereby reducing morbidity and mortality. Historically, the upper gastrointestinal (UGI) series has been the preferred imaging modality for the evaluation of both midgut malrotation and volvulus, although use of ultrasound (US) is increasing. In this narrative review, we describe the findings of midgut malrotation and volvulus on US, including practical tips for acquisition and interpretation; discuss the advantages and challenges of both imaging modalities; and propose a path and safeguards for possible transition to the use of US as the first-line modality for diagnosis, based on our experience in imaging children with midgut malrotation and volvulus.

Diagnosis and management of intestinal rotational abnormalities with or without volvulus in the pediatric population

Intestinal malrotation is a congenital anomaly that can be associated with midgut volvulus, requiring an emergent operation in order to maintain blood supply to the compromised intestine. It results from an abnormal rotation of the intestines, leading to three types of malrotation. Non-rotation is complete failure of the intestines to rotate, while the most common configuration is associated with the cecum in the mid-upper abdomen, close to a malpositioned duodenal-jejunal (DJ) flexure. This configuration has a narrow mesentery that has a high risk of volvulus. The final form of malrotation is incomplete rotation, where the DJ flexure and cecum are malpositioned, but the mesentery is not narrowed. The benefits of performing a Ladd's procedure for these individuals is controversial. Workup for malrotation should be considered in all patients who present with abdominal pain/distention and bilious emesis. An upper gastrointestinal contrast study is 93-100% sensitive and will show a corkscrew appearance when a volvulus is present. While the basic tenets of the Ladd's procedure have not changed and include detorsion of a volvulus, adhesiolysis of Ladd's bands and broadening of the mesentery, how this is accomplished and in whom are controversial. Laparoscopic Ladd's is associated with shorter hospital stays but also has a higher incidence of recurrent volvulus compared to an open approach. Patients with heterotaxy syndrome also represent a controversial group with some studies showing no difference in post-operative complications despite a higher mortality due to underlying cardiac disease, while other studies show a low incidence of volvulus and question the need for Ladd's in those who are asymptomatic. This review highlights the major aspects of diagnosing and treating malrotation, including the pathophysiology, workup, surgical options and areas of controversy.

Gastrointestinal Emergency in Neonates and Infants: A Pictorial Essay

Gastrointestinal (GI) emergencies in neonates and infants encompass from the beginning to the end of the GI tract. Both congenital and acquired conditions can cause various GI emergencies in neonates and infants. Given the overlapping or nonspecific clinical findings of many different neonatal and infantile GI emergencies and the unique characteristics of this age group, appropriate imaging is key to accurate and timely diagnosis while avoiding unnecessary radiation hazard and medical costs. In this paper, we discuss the radiological findings of essential neonatal and infantile GI emergencies, including esophageal atresia and tracheoesophageal fistula, hypertrophic pyloric stenosis, duodenal atresia, malrotation, midgut volvulus for upper GI emergencies, and jejunoileal atresia, meconium ileus, meconium plug syndrome, meconium peritonitis, Hirschsprung disease, anorectal malformation, necrotizing enterocolitis, and intussusception for lower GI emergencies.

Five Hundred Patients With Gut Malrotation: Thirty Years of Experience With the Introduction of a New Surgical Procedure

OBJECTIVES

Define clinical spectrum and long-term outcomes of gut malrotation. With new insights, an innovative procedure was introduced and predictive models were established.

METHODS

Over 30-years, 500 patients were managed at 2 institutions. Of these, 274 (55%) were children at time of diagnosis. At referral, 204 (41%) patients suffered midgut-loss and the remaining 296 (59%) had intact gut with a wide range of digestive symptoms. With midgut-loss, 189 (93%) patients underwent surgery with gut transplantation in 174 (92%) including 16 of 31 (16%) who had autologous gut reconstruction. Ladd's procedure was documented in 192 (38%) patients with recurrent or de novo volvulus in 41 (21%). For 80 patients with disabling gastrointestinal symptoms, gut malrotation correction (GMC) surgery "Kareem's procedure" was offered with completion of the 270° embryonic counterclockwise-rotation, reversal of vascular-inversion, and fixation of mesenteric-attachments. Concomitant colonic dysmotility was observed in 25 (31%) patients.

RESULTS

The cumulative risk of midgut-loss increased with volvulus, prematurity, gastroschisis, and intestinal atresia whereas reduced with Ladd's and increasing age. Transplant cumulative survival was 63% at 10-years and 54% at 20-years with best outcome among infants and liver-containing allografts. Autologous gut reconstruction achieved 78% and GMC had 100% 10-year survival. Ladd's was associated with 21% recurrent/de novo volvulus and worsening (P > 0.05) of the preoperative National Institute of Health patient-reported outcomes measurement information system gastrointestinal symptom scales. GMC significantly (P ≤ 0.001) improved all of the symptomatology domains with no technical complications or development of volvulus. GMC improved quality of life with restored nutritional autonomy (P < 0.0001) and daily activities (P < 0.0001).

CONCLUSIONS

Gut malrotation is a clinicopathologic syndrome affecting all ages. The introduced herein definitive correction procedure is safe, effective, and easy to perform. Accordingly, the current standard of care practice should be redefined in this orphan population.

Sonographic Detection of Congenital Intestinal Malrotation: A Case Report

Intestinal malrotation is a rare fetal anomaly resulting from the failure of midgut rotation and fixation. Sonography is typically the first modality of choice for assessing pediatric pathology due to its high sensitivity, portability, real-time imaging capability, and non-ionizing technique; however, its role in diagnosing small bowel rotational anomalies remains limited and controversial. Fluoroscopic upper gastrointestinal imaging (UGI) is the primary diagnostic examination at most institutions. However, even on UGI, imaging findings may be equivocal. In such cases, sonography may provide additional information at facilities where it is not used as a primary diagnostic tool. This case report represents the first reported case showing how patient position is important as the typical vascular sonographic features of rotation were normal in one position but abnormal in another. In addition, this case shows how congenital intestinal malrotation was decisively diagnosed using sonographic imaging.

Feasibility study of a novel portable digital radiography system modified for fluoroscopy in the neonatal intensive care unit

BACKGROUND

A portable radiographic system capable of fluoroscopic imaging in the neonatal intensive care unit (NICU) potentially benefits critically ill neonates by eliminating the need to transport them to a fluoroscopy suite.

OBJECTIVE

To evaluate whether a portable bedside fluoroscopy system in the NICU can deliver comparable image quality at a similar dose rate to a standard system in a fluoroscopy suite.

MATERIALS AND METHODS

In phase A, 20 patients <3 years of age and scheduled to undergo upper gastrointestinal series (upper GI) or voiding cystourethrograms (VCUG) in the radiology fluoroscopy suite were recruited to evaluate a portable fluoroscopic unit. A modified portable radiographic system with a cassette-sized detector and an in-room fluoroscopy system were sequentially used in the same examination. Four radiologists compared the image quality of 20 images from each system using the Radlex score (1-4) for five image quality attributes. The radiation dose rates for the portable and in-suite systems were collected. In phase B, fluoroscopy studies were performed in 5 neonates in the NICU and compared to the 20 previous neonatal studies performed in the department. Clinical workflow, examination time, fluoroscopy time, scattered radiation dose and patient radiation dose were evaluated.

RESULTS

In phase A, average dose rates for in-room and portable systems were equivalent, (0.322 mGy/min and 0.320 mGy/min, respectively). Reader-averaged Radlex scores for in-room and portable systems were statistically significantly greater (P<0.05) for all attributes on the portable system except for image contrast. In phase B, scattered radiation from the average fluoroscopy time (26 s) was equivalent to the scattered radiation of 2.6 portable neonatal chest radiographs. Procedure time and diagnostic quality were deemed equivalent. The average dose rate in the NICU with the portable system was 0.21 mGy/min compared to 0.29 mGy/min for the in-room system.

CONCLUSION

The portable fluoroscopy unit is capable of providing comparable image quality at equivalent dose levels to an in-room system for neonates with minimal risks to the staff and other patients in the NICU.

Right-sided Bochdalek hernia in an adult with hepatic malformation and intestinal malrotation

BACKGROUND

Bochdalek hernia is a common congenital diaphragmatic defect that usually manifests with cardiopulmonary insufficiency in neonates. It is very rare in adults, and symptomatic cases are mostly left-sided. Diaphragmatic defects generally warrant immediate surgical intervention to reduce the risk of incarceration or strangulation of the displaced viscera.

CASE PRESENTATION

A 47-year-old woman presented with dyspnea on exertion. Computed tomography revealed that a large part of the intestinal loop with superior mesenteric vessels and the right kidney were displaced into the right thoracic cavity. Preoperative three-dimensional (3D) simulation software visualized detailed anatomy of displaced viscera and the precise location and size of the diaphragmatic defect. She underwent elective surgery after concomitant pulmonary hypertension was stabilized preoperatively. The laparotomic approach was adopted. Malformation of the liver and the presence of intestinal malrotation were confirmed during the operation. The distal part of the duodenum, jejunum, ileum, colon, and right kidney were reduced into the abdominal cavity consecutively. A large-sized oval defect was closed with monofilament polypropylene mesh. No complications occurred postoperatively.

CONCLUSION

Symptomatic right-sided Bochdalek hernia in adults is exceedingly rare and is frequently accompanied by various visceral anomalies. Accurate diagnosis and appropriate surgical repair are crucial to prevent possible incarceration or strangulation. The preoperative 3D simulation provided comprehensive information on anatomy and concomitant anomalies and helped surgeons plan the operation meticulously and perform procedures safely.

Congenital positional anomaly of descending colon and sigmoid colon: Its embryological basis and clinical implications

The rotation of the midgut is essential for normal placement of intestines in the abdominal cavity. The process of midgut rotation and simultaneous retraction of the herniated intestinal loops pushes the hind gut to the left side of the abdominal cavity. So the descending colon and the sigmoid colon occupy the left side of the abdominal cavity. In this report, we document a male cadaver that revealed right-sided sigmoid colon. On further dissection, the descending colon was found lying in the midline with a small peritoneal fold stretching from the right side of sigmoid colon to ileocecal junction. There was also variation in the inferior mesenteric artery supplying the displaced descending colon and sigmoid colon. The possible embryological and molecular basis of this variation has been discussed. The anatomical knowledge of this variation is essential for interventional and diagnostic colonoscopy procedures and colonic surgeries.

Untwisting the complexity of midgut malrotation and volvulus ultrasound

Abdominal US is emerging as an alternative to the upper gastrointestinal (GI) series as the preferred diagnostic imaging test for midgut malrotation complicated by volvulus. Unlike the upper GI series, US is free from ionizing radiation, does not require oral contrast agent, and can be performed portably and at times remotely from the interpreting radiologist, expediting diagnosis. Although some institutions do not have a standardized US protocol for midgut volvulus, many routinely use US in the setting of an infant or child with acute abdominal signs or symptoms to evaluate for common conditions such as hypertrophic pyloric stenosis, intussusception, necrotizing enterocolitis and appendicitis. Because these common conditions can overlap in age and clinical presentation with midgut volvulus, the aim of this pictorial essay is to provide instruction on the technique and diagnostic findings of midgut volvulus on US to ensure confident, accurate interpretation, and prompt treatment.

A case of reversed intestinal rotation revealed by volvulus in adult: anatomo-radiological correlations

We report a case of reversed rotation (RR) of the midgut, the rarest form of intestinal malrotation (IMR), revealed by a chronic volvulus, in a 42-year-old woman presenting with episodes of abdominal pain occurring after heavy meals. The complete preoperative diagnosis was obtained by contrast-enhanced computed tomography (CT). Classical signs of volvulus were associated with typical findings of RR comprising an unusual position of the third duodenum in front of the mesenteric vessels and a very unusual location of the transverse colon behind these vessels. Complete absence of fixation of the right colon allowed secondary volvulus. A detailed reminder of the embryology of IMR and RR is presented.

Congenital hyperinsulinism: 2 case reports with different rare variants in ABCC8

Congenital hyperinsulinism (CHI) is a rare glucose metabolism disorder characterized by unregulated secretion of insulin that leads to hyperinsulinemic hypoglycemia (HH). Most cases are caused by mutations in the KATP-channel genes ABCC8 and KCNJ11. We report 2 patients that experienced severe HH from the first day of life. Patient 1 developed midgut volvulus after initiating diazoxide and required intestinal resection. He was subsequently managed with a high-dose octreotide and glucose-enriched diet. Consistent with diffuse type CHI by 18F-dihydroxyphenylalanine positron emission tomography-computed tomography, genetic testing revealed a homozygous ABCC8 variant, c.1801G>A, p.(Val601Ile). The rare variant was previously reported to be diazoxide-responsive, and the patient responded well to diazoxide monotherapy, with clinical remission at 2 years of age. Patient 2 responded to diazoxide with spontaneous clinical remission at 15 months of age. However, an oral glucose tolerance test at 7 years of age revealed hyperinsulinism. Genetic testing revealed that the proband and several seemingly healthy family members harbored a novel, heterozygous ABCC8 variant, c.1780T>C, p.(Ser594Pro). Genetic findings identified previously unrecognized HH in the proband's mother. The proband's uncle had been diagnosed with monogenic ABCC8-diabetes and was successfully transitioned from insulin to glibenclamide therapy. We report findings of intestinal malrotation and volvulus occurring 2 days after initiation of diazoxide treatment. We also report a novel, heterozygous ABCC8 variant in a family that exhibited cases of CHI in infancy and HH and monogenic diabetes in adult members. The cases demonstrate the importance and clinical utility of genetic analyses for informing and guiding treatment and care.

Ligament of Treitz: Anatomy, Relevance of Radiologic Findings, and Radiologic-Pathologic Correlation

OBJECTIVE. The objective of this article is to discuss the anatomy, embryonic origin, normal variants, and various attachments of the ligament of Treitz. We also describe the pathologic processes that develop along the ligament of Treitz and the role of cross-sectional imaging in identifying these conditions. CONCLUSION. The ligament of Treitz, also known as the suspensory ligament of the duodenum, is an important anatomic landmark in the abdomen. It is essential that radiologists understand the anatomic attachments, normal variants, and various pathologic conditions involving the ligament of Treitz as well as the role of cross-sectional imaging in the assessment of these conditions.

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.

ACR Appropriateness Criteria® Vomiting in Infants

Vomiting in infants under the age of 3 months is one of the most common reasons for parents to seek care from their doctor or present to an emergency room. The imaging workup that ensues is dependent on several factors: age at onset, days versus weeks after birth, quality of emesis, bilious or nonbilious vomiting, and the initial findings on plain radiograph, suspected proximal versus distal bowel obstruction. The purpose of these guidelines is to inform the clinician, based on current evidence, what is the next highest yield and most appropriate imaging study to pursue a diagnosis. The goal is rapid and accurate arrival at a plan for treatment, whether surgical or nonsurgical. The following modalities are discussed for each variant of the symptom: plain radiography, fluoroscopic upper gastrointestinal series, fluoroscopic contrast enema, ultrasound of the abdomen, nuclear medicine gastroesophageal reflux scan. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Diagnostic decision-making tool for imaging term neonatal bowel obstruction

Term neonatal bowel obstruction is common, and absence of treatment is potentially catastrophic. There is a relatively narrow differential diagnosis, with causes categorised as either low or high bowel obstruction. The commonest causes of low bowel obstruction include anorectal malformations (ARM), Hirschsprung's disease, ileal atresia, meconium ileus, meconium plug, and colonic atresia. The commonest causes of high bowel obstruction include duodenal atresia, duodenal stenosis/web, jejunal atresia, and malrotation with volvulus (and hypertrophic pyloric stenosis usually presenting in slightly older infants). Diagnosis can be decided using a step-wise binary decision tool that includes the appropriate imaging steps and evaluation of bowel calibre. This paper presents the decision-making tool from the presenting features, through plain radiographic findings and, where necessary, the additional radiological investigations to assist the general radiologist, novice paediatric radiologist and paediatric surgeon. The tool is pictorial, with the radiological findings accompanied by eight schematics, serving as a simplified visual aid for memorizing the imaging patterns of the differential diagnosis. The imaging and decision-making steps allow for a rapid, simplified diagnosis that can benefit patients by recommending when to perform surgery, when to perform further imaging, and when imaging can act in a therapeutic manner.

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.

Unusual intraoperative finding of abnormal retroperitoneal ileum: a case report

A 52-year-old female patient diagnosed with an adenocarcinoma of the sigmoid colon underwent anterior resection with direct anastomosis. Intraoperatively, we found the ileum completely retroperitonealized. Previously, the patient was asymptomatic and no congenital syndromes were diagnosed. The intraoperative finding of abnormal anatomy made the mobilization of the left hemicolon and the vessel ligation more challenging. This anatomical situation is a rare variation due to an embryonic malrotation, which occurs in about 1:500 newborns.

Fluoroscopic Diagnosis of Malrotation: Technique, Challenges, and Trouble Shooting

A fluoroscopic upper gastrointestinal series is the most commonly used investigation for the diagnosis of malrotation and midgut volvulus. However, both false positive and false negative results can occur causing diagnostic confusion. Several physiologic states and pathologic conditions can mimic fluoroscopic appearance of malrotation. Proper fluoroscopic technique is essential to maximize diagnostic accuracy. In this pictorial essay, we discuss common diagnostic challenges in the diagnosis of malrotation and strategies radiologists can use to clarify the diagnosis in equivocal cases.

Characterisation of computed tomography angiography findings in paediatric patients with heterotaxy

BACKGROUND

Heterotaxy refers to the abnormal arrangement of organs across the left-right axis and is typically associated with complex cardiovascular malformations.

OBJECTIVE

To characterise the range of cardiac and extracardiac CT angiography findings in children with heterotaxy using the latest nomenclature consensus and to compare the different types of isomerism.

MATERIALS AND METHODS

We retrospectively analysed the data of 64 consecutive paediatric patients referred to our tertiary paediatric cardiovascular centre who underwent CT angiography for the evaluation of known or suspected heterotaxy within a 52-month period.

RESULTS

Right atrial isomerism was identified in 44 (69%) children, while left atrial isomerism was identified in 18 (28%) children. Atrial appendage anatomy and situs could not be determined in 2 children (3%). Associated heart defects included complete atrioventricular canal (CAVC) in 51 (80%) children, total anomalous pulmonary venous return in 43 (67%) and pulmonary atresia in 23 (36%). The bronchial branching pattern corresponded to atrial appendage morphology in all children except in the two in whom atrial appendage morphology could not be defined. In children with right atrial isomerism, the most common associated abnormalities were CAVC (n=41, 93%) and asplenia (n=34, 77%), while in those with left atrial isomerism, the most common associated abnormalities were polysplenia (n=17, 94%) and an interrupted inferior vena cava with azygos continuation (n=15, 83%).

CONCLUSION

CT angiography provides useful cardiovascular and extracardiac data on heterotaxy, which frequently involves a pattern of side-related findings but has great anatomical variability.

Polysplenia syndrome with situs ambiguous, common mesentery, and IVC interruption discovered incidentally in an adult

Polysplenia syndrome associates multiple spleens to other malformations, most frequently cardiac, vascular, visceral, and biliary malformations. Polysplenia has been described mainly in childhood owing to critical anatomic malformations related to cardiac defects or biliary atresia. We present a case of polysplenia syndrome found in a 58-year-old man. Only those with mild anatomical abnormalities reach adulthood without a diagnosis. Radiological examinations are helpful to the diagnosis by ascertaining the location and number of spleens, location of other organs in the chest and abdomen, and identification of other associated anomalies.

Delayed Laparoscopic Cholecystectomy in a Case of Acute Cholecystitis and Intestinal Malrotation Type I

In adults, intestinal malrotation is an oligosymptomatic entity that is occasionally discovered during the course of diagnostic studies for other causes. In the case described herein, intestinal malrotation was discovered during investigation for cholelithiasis and acute cholecystitis. Malrotation may occur due to alterations in the asymmetric cellular dynamics of the mesentery responsible for intestinal shortening and unilateral retraction, this may occur as a secondary event following alterations in the expression of homeodomain transcription factors. The incidental finding of asymptomatic intestinal malrotation in adults does not preclude its surgical treatment. However, when intestinal malrotation is associated with cholecystitis, due to cholelithiasis, it is advisable, to first treat the cholecystitis conservatively, in our case, and then perform partial adhesiolysis of the Ladd bands that hinder access to the cystic area and carry out cholecystectomy by elective laparoscopy.