Ultrasound as the first line investigation for midgut malrotation: a UK tertiary centre experience

Ultrasound for infantile midgut malrotation: Techniques, pearls, and pitfalls

Midgut malrotation with volvulus is a surgical emergency with potentially devastating outcomes which include short gut syndrome necessitating long-term parenteral nutrition, overwhelming sepsis, and death. The clinical presentation is most frequently with bilious vomiting in the first days-weeks of life, which is non-specific and common. Timely imaging investigation is therefore crucial to prevent delays to diagnosis and treatment and avoid unnecessary surgical exploration in infants with non-surgical bilious vomiting. Fluoroscopic upper gastrointestinal contrast series (UGI) has been the first-line imaging modality to investigate midgut malrotation at pediatric surgical centers worldwide. However, there is a growing body of evidence to indicate that ultrasound (US) has greater diagnostic accuracy than UGI in this context. Furthermore, US offers the benefits of accessibility, portability, lack of ionizing radiation, and the ability to identify alternative diagnoses, and is beginning to attract significant attention and consideration in the literature. Over the last 3 years, we have transitioned to an "US-first" pathway for the investigation of midgut malrotation in infants with bilious vomiting. This pictorial essay illustrates our comprehensive approach, describes unique troubleshooting techniques, and highlights the variably published pitfalls we have encountered with the aim of encouraging wider adoption.

Ileocaecal Volvulus With an Intestinal Rotational Abnormality and Internal Hernia in a Paediatric Patient: A Case Report

Background: Caecal volvulus in the paediatric population is uncommon, yet at worst this condition is a life-threatening surgical emergency. In children, caecal volvulus can be associated with a variety of predisposing factors such as chronic constipation, intestinal malrotation, or neurological disease. Case Representation: We present a rare case of caecal volvulus, internal hernia, and an intestinal rotational abnormality in a previously healthy 8-year-old boy. The patient presented with a history of abdominal pain and vomiting for 3 days and was admitted to the hospital in a severe septic shock. After the initial stabilisation with fluids and vasopressors, an emergency laparotomy was performed. A necrotic caecum volvulus, a transmesocolic hernia, and an abnormal rotation of the small intestine were diagnosed. The necrotic bowel segment was resected in a right-sided hemicolectomy, after which a resection distal to medial colic artery was cut-off to achieve normal anatomy. The patient was discharged on the 12th postoperative day in good health and has since returned to normal active life without any health issues within the follow-up of 5 months. Conclusions: Caecal volvulus and internal hernia can lead to a life-threatening condition requiring immediate surgical treatment. Rare causes of abdominal pain in children should be kept in mind when severe symptoms are present.