pediatrics
Malrotation of the Bowel
Diagnosis of Malrotation of the Bowel
Abdominal x-rays Barium enema and/or upper GI series In infants with bilious emesis, plain x-rays of the abdomen should be done immediately. If they suggest obstruction, for example showing a dilated stomach and proximal small bowel (double-bubble sign), a paucity of bowel gas distal to the duodenum, or both (suggesting a midgut volvulus), further diagnosis and treatment must be done emergently. Barium enema typically identifies malrotation by showing the cecum outside the right lower quadrant. If the diagnosis remains uncertain, an upper GI series can be done cautiously. If plain x-rays are nonspecific and no obstruction is present, clinicians sometimes begin with an upper GI series because this may detect other conditions that cause similar symptoms. In nonemergent situations, the definitive imaging for malrotation is an upper GI series. Studies have investigated the use of ultrasonography to diagnose malrotation by looking for retromesenteric localization of the third portion of the duodenum, or reversed mesenteric vessel position and the whirlpool sign (bowel wrapped around the superior mesenteric artery in a whirlpool-like pattern). The use of ultrasonography depends on the availability of an experienced radiologist or radiology technician. At the present time, an upper GI series is the standard diagnostic technique for malrotation with or without volvulus ( Diagnosis references , 1.Graziano K, Islam S, Dasgupta R, et al: Asymptomatic malrotation: Diagnosis and surgical management: An American Pediatric Surgical Association outcomes and evidence based practice committee systematic review.J Pediatr Surg50:1783–1790, 2015. doi: 10.1016/j.jpedsurg.2015.06.019 2.Zhou LY, Li SR, Wang W, et al: Usefulness of sonography in evaluating children suspected of malrotation: Comparison with an upper gastrointestinal contrast study.J Ultrasound Med34:1825–1832, 2015. doi: 10.7863/ultra.14.10017 