intestinal malrotation and volvulus

Newborn with

bilious vomiting who continued to have bilious vomiting after a Ladd procedure. AP (above left) and lateral (above right) images from an upper GI exam on day of life 1 show dilation of the first part of the duodenum and a spiral or corkscrew appearance of the second and third parts of the duodenum with the ligament of Trietz projecting over the midline of the spine and lower than the first part of the duodenum. AP (below left) and lateral (below right) images from an upper GI obtained several days after a Ladd procedure show the first part of the duodenum now to be normal in caliber while the second and third parts of the duodenum continue to have a spiral or corkscrew appearance with the ligament of Trietz continuing to project over the midline of the spine and lower than the first part of the duodenum.The diagnosis was malrotation with midgut volvulus on the initial upper GI exam and malrotation without midgut volvulus after a Ladd procedure on the repeat upper GI exam.

Teenager with

chronic abdominal pain. AP image from a small bowel follow through exam (below) shows the small bowel on the right side of the abdomen and the colon on the left side of the abdomen. Close examination of the upper GI portion of the exam (above) beyond the abnormal position of the ligament of Treitz shows a thickened appearance of the folds throughout the duodenum (above left) and proximal jejunum (above right) but there was no evidence of spiraling of the bowel or obstruction.The diagnosis on the upper GI was malrotation without midgut volvulus. In the operating room the patient was found to have malrotation with chronic midgut volvulus with chronically dilated lymphatic and mesenteric venous systems which were the cause of the thickened appearance of the small bowel folds.

Newborn with

bilious vomitingTwo AP images from an upper GI exam show the duodenal-jejunal junction to be to the left of the spine but to be low lying. The proximal jejunum has a spiral appearance.The diagnosis was malrotation with midgut volvulus.

Infant with

projectile vomiting. Transverse US of the pylorus (left) showed a normal appearing pylorus and showed the superior mesenteric vein to be directly above the superior mesenteric artery (the round structure with an echogenic rim in the center of the image), raising suspicion for malrotation. AP image from an UGI exam (right) shows the duodenal jejunal junction to be over the right pedicle of the spine and to be below the level of the duodenal bulb.The diagnosis was malrotation with midgut volvulus.

Newborn with

3 days of bilious vomiting. Serial AP images from an UGI exam show dilation of the first and second parts of the duodenum, the ligament of Treitz projects over the midline of the spine and lower than the duodenal bulb, and the third portion of the duodenum has a spiral or corkscrew appearance.The diagnosis was malrotation with midgut volvulus.

Newborn with

bilious vomiting. AP image from an UGI exam shows dilation of the first and second parts of the duodenum. The ligament of Treitz was located in the middle of the spine and was in a lower position than the duodenal bulb. The proximal jejunum was in the right upper quadrant.The diagnosis was malrotation with midgut volvulus.

Infant with

bilious vomiting. Early AP image from an UGI exam (above) showed the ligament of Treitz to project over the midline of the spine and at the same level as the duodenal bulb. Later image (below left) showed the proximal jejunum in the right upper quadrant. Final image (below right) after following contrast through to the colon showed the cecum to be on the right side of the abdomen but to be high in position. The patient was surgically explored and in the operating room the ligament of Treitz was seen in the left upper quadrant and there was normal rotation of the bowel.The diagnosis was false positive diagnosis of malrotation with midgut volvulus.

Newborn with

bilious vomiting. AP image from an UGI exam (left) shows dilation of the stomach and first and second parts of the duodenum. There is an abrupt transition in bowel counter at the ligament of Treitz which projects low in position and over the middle of the spine. The jejunum then appears to spiral away downstream. AP image from later in the exam (right) better shows the spiraling / corkscrew appearance of the proximal jejunum.The diagnosis was malrotation with midgut volvulus.

Midgut

volvulus in an infant with intestinal malrotation. Abdominal radiograph revealing paucity of bowel gas distal to the duodenum.

Midgut

volvulus in an infant with intestinal malrotation. Upper gastrointestinal imaging at delayed phase revealing dilated stomach and proximal duodenum with stagnation of the contrast.

Infant with

bilious vomiting for several days and a tender abdomen. AXR supine shows multiple dilated loops of bowel with thickened walls.The diagnosis was small bowel obstruction. In the operating room the patient was found to have malrotation with midgut volvulus. The small bowel was non-viable.

Midgut

volvulus in an infant with intestinal malrotation. Ultrasonography with colour Doppler showing an inversion of the position of the SMA and SMV.

Newborn with

bilious vomiting. AP image from an upper GI shows complete obstruction of the duodenum at the junction of the second and third parts of the duodenum and associated massive gastroesophageal reflux. A final image taken 5 minutes later was unchanged.The diagnosis was gastroesophageal reflux due to malrotation with midgut volvulus causing duodenal obstruction.

Infant with

bilious vomiting. AP image from an upper GI (left) shows the ligament of Treitz projecting over the right pedicle of the L2 vertebral body and to be lower in position than the duodenal bulb that projects over the right pedicle of the L1 vertebral body. The spiral appearance of the proximal jejunum is best appreciated on the lateral image (right).The diagnosis was malrotation with midgut volvulus.

Infant with

bilious vomiting. AP image from an UGI exam (above) shows the duodenal jejunal junction to project to the left of the spine in its normal position. Later image from the exam (below) shows the jejunum to be on the right side, rather than the left side, of the abdomen.The diagnosis was normal rotation of the bowel with no evidence of malrotation with midgut volvulus.

Midgut

volvulus in an infant with intestinal malrotation. Ultrasonography showing an epigastric mass with a typical whirlpool pattern (arrow).

Midgut

volvulus in an infant with intestinal malrotation. Ultrasonography without colour Doppler showing an inversion of the position of the SMA and the SMV.