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Kedoin C, Muto M, Nagano A, Matsui M, Sugita K, Baba T, Miyoshi K, Masuya R, Murakami M, Yano K, Onishi S, Harumatsu T, Yamada W, Yamada K, Matsukubo M, Kawano T, Kuda M, Nakame K, Torikai M, Ieiri S. Notable Clinical Differences Between Neonatal and Post-Neonatal Intestinal Malrotation: A Multicenter Review in Southern Japan. J Pediatr Surg 2024; 59:566-570. [PMID: 38145920 DOI: 10.1016/j.jpedsurg.2023.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 11/20/2023] [Indexed: 12/27/2023]
Abstract
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.
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Affiliation(s)
- Chihiro Kedoin
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Mitsuru Muto
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.
| | - Ayaka Nagano
- Department of Pediatric Surgery, Kagoshima City Hospital, Kagoshima, Japan
| | - Mayu Matsui
- Department of Pediatric Surgery, Kagoshima City Hospital, Kagoshima, Japan
| | - Koshiro Sugita
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Tokuro Baba
- Department of Digestive and General Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Kina Miyoshi
- Department of Pediatric Surgery, Miyazaki Prefectural Miyazaki Hospital, Miyazaki, Japan
| | - Ryuta Masuya
- Division of the Gastrointestinal, Endocrine, and Pediatric Surgery, Department of Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Masakazu Murakami
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Keisuke Yano
- Department of Neonatology, Perinatal Medical Center, Kagoshima City Hospital, Kagoshima, Japan
| | - Shun Onishi
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Toshio Harumatsu
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Waka Yamada
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Koji Yamada
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Makoto Matsukubo
- Department of Pediatric Surgery, Kagoshima City Hospital, Kagoshima, Japan
| | - Takafumi Kawano
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Masaaki Kuda
- Department of Digestive and General Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Kazuhiko Nakame
- Division of the Gastrointestinal, Endocrine, and Pediatric Surgery, Department of Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Motofumi Torikai
- Department of Pediatric Surgery, Kagoshima City Hospital, Kagoshima, Japan
| | - Satoshi Ieiri
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
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Maya‐Enero S, Prat‐Ortells J, Martín‐Solé O, De Haro‐Jorge I, Pertierra‐Cortada À, Iriondo‐Sanz M. Distinguishing outcomes of neonatal intestinal volvulus: Review of our experience over the last 20 years. Acta Paediatr 2022; 111:284-290. [PMID: 34704280 DOI: 10.1111/apa.16167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/29/2021] [Accepted: 10/25/2021] [Indexed: 12/01/2022]
Abstract
AIM There are two types of intestinal volvulus: midgut (MGV) and segmental (SV). Patients with different types of intestinal volvulus are often included in the same case series, which may affect the perception of how severe "intestinal volvuli" are. We aimed to compare both types of intestinal volvulus. METHODS This is a retrospective observational study including all patients with MGV and SV up to 28 days of life admitted to a tertiary hospital in Spain over a 20-year-period (1999-2019). A comparison between groups and a logistic regression model for mortality were done. RESULTS We identified 32 patients: 23 MGV and 9 SV. Malrotation was exclusive of MGV. Prenatal diagnosis, cystic fibrosis, and intestinal resection were significantly more frequent in SV. Surgery was performed at a significantly lower age in SV. The mortality observed in acute MGV with intestinal compromise (41.7%) is four times higher than the mortality of SV (11.1%). The overall mortality of all MGV patients (21.7%) is almost twice that of SV. Mortality was best predicted by the presence of hemodynamic instability (OR 27.5 95% CI 2.50-302.17; p = 0.007). CONCLUSION SV and MGV have a different clinical presentation. Hemodynamic instability is the major risk factor for death.
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Affiliation(s)
- Silvia Maya‐Enero
- Department of Neonatology Service of Pediatrics, Hospital del Mar Universitat Autònoma de Barcelona Barcelona Spain
| | - Jordi Prat‐Ortells
- Service of Pediatric Surgery Hospital Sant Joan de DéuUniversitat de Barcelona Barcelona Spain
| | - Oriol Martín‐Solé
- Service of Pediatric Surgery Hospital Sant Joan de DéuUniversitat de Barcelona Barcelona Spain
| | - Irene De Haro‐Jorge
- Service of Pediatric Surgery Hospital Sant Joan de DéuUniversitat de Barcelona Barcelona Spain
| | | | - Martín Iriondo‐Sanz
- Service of Neonatology Hospital Sant Joan de DéuUniversitat de Barcelona Barcelona Spain
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Salim A, Moazzam Z, Ashraf A, Dogar SA, Qazi SH. Congenital absence of the appendix in a child with malrotation. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2020. [DOI: 10.1016/j.epsc.2020.101530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Botchway E, Tshifularo N, Human M. Mesenteric cyst as a presentation of chronic midgut volvulus in a 12 year old boy. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2020. [DOI: 10.1016/j.epsc.2019.101351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Matijasic N, Plesa Premilovac Z. Inconsolable Crying in Infants: Differential Diagnosis in the Pediatric Emergency Department. Clin Pediatr (Phila) 2019; 58:133-139. [PMID: 30175595 DOI: 10.1177/0009922818798389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Abstract
Care of the ill and injured child requires knowledge of unique pediatric anatomic and physiologic differences. Subtleties in presentation and pathophysiologic differences impact management. This article discusses pediatric resuscitation, the presentation and management of common childhood illness, pediatric trauma, and common procedures required in the critically ill child.
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Abstract
The evaluation of the child with acute abdominal pain often poses as a diagnostic challenge due to the wide range of diagnoses. Surgical emergencies need to be rapidly identified and managed appropriately to minimize morbidity and mortality. Presenting symptoms, clinical examination, and laboratory findings can guide selection of diagnostic imaging. This article reviews common surgical causes of abdominal pain in children.
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Sizemore AW, Rabbani KZ, Ladd A, Applegate KE. Diagnostic performance of the upper gastrointestinal series in the evaluation of children with clinically suspected malrotation. Pediatr Radiol 2008; 38:518-28. [PMID: 18265969 DOI: 10.1007/s00247-008-0762-8] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2007] [Revised: 12/14/2007] [Accepted: 01/08/2008] [Indexed: 12/30/2022]
Abstract
BACKGROUND Malrotation is a congenital disorder of abnormal intestinal rotation and fixation that predisposes infants to potentially life-threatening midgut volvulus. Upper gastrointestinal tract (UGI) examination is sometimes equivocal and can lead to inaccurate diagnosis. OBJECTIVE To determine the diagnostic performance of UGI examinations in children who subsequently underwent a Ladd procedure for suspected malrotation or volvulus. MATERIALS AND METHODS We reviewed all children up to 21 years old who had undergone both a UGI examination and a Ladd procedure for possible malrotation across 9 years. Children were excluded if they had not undergone either a UGI examination or a Ladd procedure and if congenital abdominal wall defects were present. RESULTS Of 229 patients identified, 166 (59% male, median age 67 days) were included. Excluded were 47 without a UGI series, 12 with omphalocele or gastroschisis, 1 without verifiable operative data, 1 who had not undergone a Ladd procedure, and 2 older than 21 years. Of the 166 patients, 40% were neonates and 73% were <12 months old, and 31% presented with bilious vomiting and 15% with abdominal distention. Of 163 patients with surgically verified malrotation, 156 had a positive UGI examination, a sensitivity of 96%. There were two patients with a false-positive UGI examination and seven with false-negative examination. Jejunal position was normal in six of the seven with a false-negative examination and abnormal in the two with a false-positive examination. Of 38 patients with surgically verified volvulus, 30 showed volvulus on the UGI series. Five required bowel resection and three died. CONCLUSION Jejunal position can lead to inaccurate UGI series interpretation. Meticulous technique and periodic assessment of performance will help more accurately diagnose difficult or equivocal cases.
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Affiliation(s)
- Alecia W Sizemore
- Department of Radiology, Indiana University School of Medicine, Indianapolis, IN, USA
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Affiliation(s)
- Peter J Strouse
- C.S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, Michigan 48109-0252, USA.
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Louie JP. Essential Diagnosis of Abdominal Emergencies in the First Year of Life. Emerg Med Clin North Am 2007; 25:1009-40, vi. [DOI: 10.1016/j.emc.2007.07.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Green P, Swischuk LE, Hernandez JA. Delayed presentation of malrotation and midgut volvulus: imaging findings. Emerg Radiol 2007; 14:379-82. [PMID: 17710454 DOI: 10.1007/s10140-007-0662-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2007] [Accepted: 07/28/2007] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Page Green
- Department of Radiology, University of Texas Medical Branch, Galveston, TX 77555-0709, USA
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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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Walker GM, Neilson A, Young D, Raine PAM. Colour of bile vomiting in intestinal obstruction in the newborn: questionnaire study. BMJ 2006; 332:1363. [PMID: 16737979 PMCID: PMC1476724 DOI: 10.1136/bmj.38859.614352.55] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To identify the colour that different groups of observers thought represented bile in a newborn's vomit. DESIGN Questionnaires displaying eight colours (pale yellow to dark green). SETTING General practices in Glasgow, postnatal ward and level III special care baby unit in a university teaching hospital, and mother and toddler groups in Glasgow. PARTICIPANTS 47 general practitioners, 29 nurses on the baby unit, 48 midwives, and 41 mothers of babies and infants. OUTCOME MEASURES Participants indicated which colour would represent bile in a baby's vomit. More than one colour could be chosen. Respondents were also asked to indicate one colour that was the best match for bile. RESULTS When any colour could be chosen, 12 (25%) general practitioners, 1 (3%) nurse on the baby unit, 5 (10%) postnatal midwives, and 23 (56%) parents did not consider green an appropriate colour for a baby's vomit containing bile. Twenty three (49%) general practitioners, 7 (24%) neonatal nurses, 15 (31%) postnatal midwives, and 29 (71%) parents thought yellow was the best colour match. CONCLUSIONS There is little agreement about the colour of bile vomit in a newborn. It is more pertinent to ask parents about the colour of vomit rather than whether it contained bile. Many general practitioners and parents do not recognise green as an appropriate colour for bile in the vomit of newborns, which may delay surgical referral. Though yellow vomit does not exclude intestinal obstruction, the presence of green vomiting in a baby is a surgical emergency and requires expeditious referral.
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Affiliation(s)
- Gregor M Walker
- Department of Paediatric Surgery, Royal Hospital for Sick Children, Glasgow G3 8SJ.
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Berrocal T, Gayá F, de Pablo L. Aspectos embriológicos, clínicos y radiológicos de la malrotación intestinal. RADIOLOGIA 2005. [DOI: 10.1016/s0033-8338(05)72843-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Romano S, Tortora G, Palomba R, de Stefano G, Merola S, Romano L. MDCT findings of intestinal ischemia due to midgut torsion without small bowel obstruction in a 12-year-old boy. Emerg Radiol 2005; 11:236-8. [PMID: 16133613 DOI: 10.1007/s10140-005-0401-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2004] [Accepted: 12/20/2004] [Indexed: 01/13/2023]
Abstract
Intestinal ischemia in the pediatric age group is a rare occurrence. We describe a case of MDCT findings of ischemia due to midgut torsion without intestinal obstruction in a 12-year-old boy, successfully submitted to surgery without any intestinal resection required.
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Affiliation(s)
- Stefania Romano
- Department of Diagnostic Imaging, A. Cardarelli Hospital, Naples, Italy.
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Strouse PJ. Disorders of intestinal rotation and fixation ("malrotation"). Pediatr Radiol 2004; 34:837-51. [PMID: 15378215 DOI: 10.1007/s00247-004-1279-4] [Citation(s) in RCA: 126] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2004] [Accepted: 06/15/2004] [Indexed: 11/29/2022]
Abstract
Malrotation with volvulus is one of the true surgical emergencies of childhood. Prompt radiological diagnosis is often paramount to achieving a good outcome. An understanding of the normal and anomalous development of the midgut provides a basis for understanding the pathophysiology and the clinical presentation of malrotation and malrotation complicated by volvulus. In this essay, the radiologic findings of malrotation and volvulus are reviewed and illustrated with particular attention to the child with equivocal imaging findings.
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Affiliation(s)
- Peter J Strouse
- Section of Pediatric Radiology, C.S. Mott Children's Hospital, University of Michigan Medical Center, 1500 East Medical Center Drive, MI, Ann Arbor 48109-0252, USA.
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El-Matary W, Jones M, Wright N, Dalzell M. Intestinal malrotation: an unusual presentation. Eur J Pediatr 2003; 162:812-3. [PMID: 14505050 DOI: 10.1007/s00431-003-1308-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2003] [Accepted: 08/05/2003] [Indexed: 10/26/2022]
Affiliation(s)
- Wael El-Matary
- Gastroenterology Unit, The Royal Liverpool Children's NHS Trust Alder Hey, Eaton Road, L12 2AP Liverpool, UK.
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Abstract
Malrotation of the intestines occurs as a result of failure of normal intestinal rotation and fixation during early pregnancy. This study examined the epidemiology of malrotation in Hawaii during 1986-99, using data from a population-based birth defects registry. There were 81 cases of malrotation, resulting in a rate of 2.86 per 10 000 live births and fetal deaths. The first-year mortality rate was 15.8%. Other major birth defects were reported for 93.8% of the cases. The malrotation rate during 1993-99 was significantly higher than the rate during 1986-92 (rate ratio [RR] 1.42, 95% confidence interval [CI] 1.04, 1.90). The malrotation rate was inversely proportional to maternal age (P = 0.028). Compared with whites, the malrotation rate was significantly higher among Far East Asians (RR 1.95, 95% CI 1.12, 3.17), Pacific Islanders (RR 2.41, 95% CI 1.63, 3.44) and Filipinos (RR 1.82, 95% CI 1.02, 3.01). Malrotation rates did not differ significantly by sex (RR 0.98, 95% CI 0.70, 1.34) or plurality (RR 1.86, 95% CI 0.38, 5.44) but were significantly higher among livebirths with birthweight < 3000 g (RR 3.90, 95% CI 2.83, 5.24). With no other population-based studies of malrotation found in the literature, this study adds to the knowledge of the epidemiology of malrotation.
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Abstract
Because young children often present to EDs with abdominal complaints, emergency physicians must have a high index of suspicion for the common abdominal emergencies that have serious sequelae. At the same time, they must realize that less serious causes of abdominal symptoms (e.g., constipation or gastroenteritis) are also seen. A gentle yet thorough and complete history and physical examination are the most important diagnostic tools for the emergency physician. Repeated examinations and observation are useful tools. Physicians should listen carefully to parents and their children, respect their concerns, and honor their complaints. Ancillary tests are inconsistent in their value in assessing these complaints. Abdominal radiographs can be normal in children with intussusception and even malrotation and early volvulus. Unlike the classic symptoms seen in adults, young children can display only lethargy or poor feeding in cases of appendicitis or can appear happy and playful between paroxysmal bouts of intussusception. The emergency physician therefore, must maintain a high index of suspicion for serious pathology in pediatric patients with abdominal complaints. Eventually, all significant abdominal emergencies reveal their true nature, and if one can be patient with the child and repeat the examinations when the child is quiet, one will be rewarded with the correct diagnosis.
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Affiliation(s)
- James D'Agostino
- Department of Emergency Medicine, State University of New York, Upstate Medical University, Syracuse, New York, USA.
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