Late presentations of midgut malrotation in children

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.

Malrotation in infancy and childhood

BACKGROUND AND AIMS

The cardinal features of bilious vomiting and abdominal distension assist in the diagnosis of malrotation and volvulus, an often fatal condition in the neonate. When these symptoms are absent, however, diagnosis becomes trickier. In the older child, these classic symptoms are less likely to occur, or occur at a later stage, meaning these children suffer from a delay in diagnosis and consequently do poorer. There is a need, therefore, to identify the common presenting features in these older children in order to facilitate earlier diagnosis and improve outcomes.

METHODS

We reviewed the current literature (Appendix 1) and then undertook a retrospective study in our own department to explore the presenting complaint, time to diagnosis, intraoperative findings and outcome of all children over the age of 28 days who underwent a Ladd's procedure for malrotation at Royal Hospital for Sick Children, Glasgow (RHSC) between 1998 and 2014.

RESULTS

It was found that children between the ages of 28 days and 15 years are more likely to display signs and symptoms such as chronic abdominal pain and non-bilious vomiting. Their complication rate was found to be significant.

CONCLUSION

Education surrounding the timely diagnosis of malrotation in the post-neonatal child is crucial.

Ultrasonographic diagnosis of midgut volvulus with malrotation in children

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Laparoscopic management of midgut malrotation and tuberculous peritonitis in an adolescent boy

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.

Delayed presentation of malrotation and midgut volvulus: imaging findings

Midgut volvulus presenting outside the neonatal period often manifests with less than classic findings. One must be ever vigilant for any deviation from normal when imaging the gastrointestinal tract in these patients. Plain films often are noncontributory, and gastrointestinal imaging findings frequently are subtle and not exactly the same as those seen in classic cases in the neonatal period. Cases are presented illustrating the following: abnormal but less than classic small bowel location and configuration, malabsorption and fortuitous spiraling of a nasogastric tube, viral gastroenteritis and pseudo intussusception, intractable vomiting and dehydration with abnormal cecal position, and duodenal obstruction: pseudo SMA syndrome. Fortunately, one now can confirm one's suspicions with computed tomography and ultrasound in terms of determining whether the superior mesenteric artery and superior mesenteric vein positions are normal or reversed.

Intestinal malrotation in children: a problem-solving approach to the upper gastrointestinal series

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.

Rare clinical presentation mode of intestinal malrotation after neonatal period: Malabsorption-like symptoms due to chronic midgut volvulus

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.

Utility of the sonographic whirlpool sign in diagnosing midgut volvulus in patients with atypical clinical presentations

OBJECTIVE

To illustrate cases of midgut volvulus in 7 children, of whom only 2 were neonates, diagnosed initially by sonography using the whirlpool sign, and to emphasize the importance of considering malrotation and midgut volvulus in the differential diagnosis of acute or chronic abdominal pain in those beyond the neonatal period, the usual time of presentation for midgut volvulus.

METHODS

The sonography computer database of a large pediatric hospital was reviewed over a 26-month period for sonographic reports that contained the key words midgut volvulus and whirlpool sign. From November 1999 until January 2002, 7 patients had a sonographic diagnosis of midgut volvulus on the basis of the whirlpool sign. Sonographic and surgical records of these patients were reviewed retrospectively. In addition, the department computer database of all contrast-enhanced upper gastrointestinal examinations performed over the same period was searched using the key words midgut volvulus, and an additional 2 cases of midgut volvulus were found, neither of which had undergone a prior or subsequent sonographic study.

RESULTS

Seven patients, ranging in age from 1 day to 5 1/2 years were found to have the whirlpool sign on sonography performed for acute abdominal symptoms, including projectile nonbilious emesis, colicky abdominal pain with suspicion of intussusception, palpable abdominal masses, right lower quadrant abdominal pain with suspected appendicitis, and chronic diarrhea. Six of the 7 cases of midgut volvulus were confirmed with upper gastrointestinal examinations. One patient was taken directly to surgery on the basis of the sonographic findings alone. One patient had subsequent computed tomography of the abdomen for continued suspicion of an abdominal mass. All 7 cases were confirmed as midgut volvulus at surgery.

CONCLUSIONS

The sonographic whirlpool sign is a valid and highly sensitive sign for the diagnosis of midgut volvulus secondary to malrotation, and sonographers should be aware that it frequently occurs beyond the neonatal period with symptoms other than bilious emesis.

Superior mesenteric venous thrombosis in malrotation with chronic volvulus

Malrotation can be difficult to diagnose after the newborn period because of intermittent symptoms and vague clinical findings, but malrotation with midgut volvulus is usually quite striking in its presentation. Early diagnosis and surgical treatment are essential to prevent acute ischemic infarction of the bowel, although chronic complications are rare. The authors present an unusual case of mesenteric venous thrombosis secondary to chronic midgut volvulus. A 13-year-old girl presented with an 11-year history of recurrent bouts of abdominal pain evaluated at 3 other institutions without a diagnosis. At the referring hospital, an episode of bilious emesis associated with abdominal pain prompted a computerized tomography scan of the abdomen. This showed a calcified thrombus within the superior mesenteric vein (SMV). At laparotomy, malrotation with chronic 270 degree volvulus was found with evidence of mesenteric venous hypertension. Segmental occlusion was documented on magnetic resonance angiography. SMV thrombosis is an unusual complication of malrotation with chronic midgut volvulus.

Malrotation of the intestine

Malrotation of the intestinal tract is a product of a well defined aberrant embryology. Because the consequences of malrotation associated with a midgut volvulus may be catastrophic, an understanding of the anatomy, diagnostic criteria, and appropriate therapy for this putative emergency illness is imperative. This report summarizes a recent 18-month experience with this diagnosis and contrasts this experience with that in the published literature. More than half (14/22) of the patients presented during the first month of life, and all had vomiting, which in most cases was bilious. The barium upper gastrointestinal series was the preferred diagnostic study, being both sensitive (18/19, 95%) and accurate (18/21, 86%). In this series two-thirds of the patients presented with volvulus (15/22, 68%) of whom five had ischemic intestine requiring resection. One of these children died of overwhelming sepsis. A Ladd procedure was the preferred treatment, which as defined by us includes evisceration and inspection of the mesenteric root, counterclockwise derotation of a midgut volvulus, lysis of Ladd's bands with straightening of the duodenum along the right abdominal gutter, inversion-ligation appendectomy, and placement of the cecum into the left lower quadrant. A high index of suspicion in the neonate with vomiting, rapid diagnosis, and appropriate operative therapy results in a predictable favorable outcome for children with intestinal malrotation.

Obstructive jaundice associated with polysplenia syndrome in an older child

Polysplenia syndrome includes malrotation and various forms of heterotaxy. Associated with this and malrotation are extrahepatic biliary anomalies. Actual obstruction, other than in associated biliary atresia, is extremely rare, and rarer still in older children. An 11-year-old girl presented with obstructive jaundice, malrotation, and heterotaxy, which were found in association with common bile duct anomalies and intermittent common bile duct obstruction. This case illustrates that the differential diagnosis of obstructive jaundice, even in older children, should include congenital anomalies, and that biliary anomalies should be considered in cases of malrotation and heterotaxy.

Clinical factors affecting mortality in children with malrotation of the intestine

In children with symptoms secondary to malrotation of the intestine, a retrospective statistical study was undertaken to identify factors associated with an increased risk of mortality. Between 1964 and 1989, laparatomy was performed on 182 children. For study purposes, the children were divided into three groups. Group I included 71 patients with an obstruction only in the duodenum. The remaining 111 children, all of whom had midgut volvulus, were further divided; those without gut necrosis (79) into group II, and those with necrosis (32) into group III. One child each died in groups I and II, and 15 in group III. In all children we evaluated the relationship between mortality and age at presentation, presence of associated serious abnormalities, time from onset of symptoms to surgery, and the presence of necrotic bowel. For group III, we considered the influence of percentage of bowel resected on mortality. In these 182 children the factors associated with an increased risk of mortality were presence of necrosis (P < .0001), presence of other abnormalities (P = .0008), and younger age (P = .0084). Time from onset of symptoms to surgery was not associated with statistically increased risk of mortality. The 1% mortality noted in children without intestinal necrosis (group I and II) was related to associated abnormality. For group III the estimated probability of survival ranged from .999 for patients with 10% of intestinal necrosis to .351 for whose with 75% of intestinal necrosis, assuming the best prognostic conditions (patient older than 3 months with no associated serious abnormalities).

Intestinal malrotation: the role of small intestinal dysmotility in the cause of persistent symptoms

To investigate the possibility that small intestinal dysmotility is a cause of long-standing and persistent symptoms in patients with malrotation, we retrospectively reviewed 94 patients operated on for intestinal malrotation. In 50 patients operated on during the neonatal period, associated abnormalities were common (24%) and all presented with obstructive symptoms; only three (6%) had continuing mild symptoms the postneonatal period (aged 1 month to 1 year), five of whom (22%) had other abnormalities. Recurrent vomiting was the most common presentation (11/23); only 5 patients (21%) had acute obstruction. Response to operation was good in 18 (78%) and two had persistant symptoms; both died. Twenty-one patients presented beyond infancy (aged greater than 1 year), only 19 of whom had symptoms of less than 2 months' duration. Eight (47%) of those with long-standing symptoms had no relief from operation. Small bowel motility was recorded manometrically in 4 patients with long-standing symptoms. The findings suggest that small intestinal dysmotility may be common in patients with malrotation and persistant symptoms.

Malrotation presenting beyond the neonatal period

The diagnosis of malrotation is easily made in the neonatal period, but is often delayed in older patients. Among 82 patients treated for malrotation in this institution, 45 patients presented with symptoms related to their malrotation, seven were diagnosed at exploration for concomitant intrinsic duodenal obstruction, and 30 patients had malrotations discovered as incidental findings at laparotomy or autopsy. Among the 45 symptomatic patients, 25 (56%) underwent surgery in the first month of life, whereas 20 patients (44%) underwent surgery at an older age. In this last group, the mean age at surgery was 51.5 months (range, 2 months to 16 years), the mean age of onset of symptoms was 2 years (range, 0 to 15 years) and the mean delay in diagnosis was 1.7 years. Although bilious vomiting was the presenting symptom among all patients undergoing surgery in the neonatal period, clinical features of older patients included intestinal obstruction (7), chronic abdominal pain (4), malabsorption/diarrhea (3), peritonitis/septic shock (2), solid food intolerance (1), common bile duct obstruction (1), abdominal distention (1), and delayed transit postappendectomy (1). The frequency of midgut volvulus was equal among both groups. Unusual forms of malrotation were more frequent in patients undergoing surgery beyond the neonatal period. In this group there was evidence of chronic venous and lymphatic obstruction with one case of superior mesenteric vein thrombosis and two cases of intestinal gangrene. A Ladd's procedure was performed in all cases and the most frequent postoperative complication was adhesive intestinal obstruction. There were no deaths. Awareness of the unusual presentation in patients who present beyond the neonatal period may help reduce delays in diagnosis and surgical treatment. We believe that laparotomy is indicated in all patients with malrotation, even if they are asymptomatic.

Reversed intestinal rotation associated with anomalous mesenteric venous drainage. Report of a case

Reverse intestinal rotation is a congenital abnormality of midgut rotation. Mesenteric arterial, venous, and lymphatic compression may occur, but associated anomalous mesenteric venous drainage is extremely rare. The case presented illustrates the importance of recognition of intestinal malrotation and the danger of bowel resection in the presence of anomalous mesenteric venous drainage.

Malrotation and midgut volvulus presenting as malabsorption

Volvulus of the midgut associated with intestinal malrotation classically presents in early life with complete, or intermittent, high intestinal obstruction. We describe the case of a boy presenting at 16 months of age with a history of malabsorption and failure to thrive. The importance of considering this rare diagnosis in such cases is discussed.