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Malrotation with Midgut Volvulus

Afiesimama BOA - MedPix (2007)

View Article: MedPix Image - MedPix Case

Affiliation: Uniformed Services University

ABSTRACT

Diagnosis: Malrotation with Midgut Volvulus

History: Nine day-old infant male who presents with bilious vomiting.

Findings: Plain film: The supine plain film of this infant at first glance demonstrates an apparent gastric outlet obstuction with a small amount of air within the proximal duodenum. The degree of gastric distention is variable, depending on the amount and frequency of vomiting. (Proximal gastric and duodenal dilatation can even be absent because of repeated emesis). There is a generalized paucity of gas distal to the apparent obstruction. The lack of distal bowel gas suggests that the mechanical obstruction is complete. Distention of gas-filled distal bowel is not seen, and there is no evidence of pneumatosis or pneumoperitoneum. These findings are relatively nonspecific, because in this supine film the duodenum is probably filled with fluid, thus making it invisible radiographically. The air in the distended stomach could erroneously suggest a gastric outlet obstruction. The "double-bubble" sign of duodenal atresia can also occur in malrotation but is not seen here. Upper GI Series: The first finding to note is the abnormal position of the nasogastric tube passing downward into an abnormally positioned jejunum. Before presenting the rest of the findings, it is important to know the normal anatomical features. The normal duodenojejunal junction, or Ligament of Treitz, is at the same level as the duodenal bulb - anterior to the left transverse process of L-1. The proximal jejunum is normally in the left abdomen. Note the persistent dilatation of the duodenal bulb and proximal duodenum, terminating in a distinctive conical shape. (The cone is hidden because of the overlying duodenal dilatation). There appears to be an obstruction of the third portion of the duodenum. In addition to this, the duodenum lies somewhat further to the right of the spine than normal (i.e. poor fixation secondary to the absence of the Ligament of Treitz). The mechanical obstruction is incomplete as evidenced by the passage of barium contrast beyond the point of obstruction into the jejunum. As the jejunum fills, it is seen to lie in an abnormal mid-abdominal and right-sided position. In this study, the "corkscrew" pattern of the small bowel (which is pathonogmonic of acute midgut volvulus) is absent. However, one can see the thickened folds of the valvulae conniventes. This is due to vascular obstruction and lymphatic engorgement. This is consistent with pathognomic spiraling of the small bowel around the superior mesenteric artery (i.e. vascular compromise can be assumed with certainty). Because of the mucosal edema, the corkscrew bowel segment may be difficult to see, especially at the most distal point of this contrast study. Finally, there is an oblique line formed by the narrowing of the contrast column. This is consistent with tight Ladd's bands.

Ddx: gastroesophageal reflux neonatal sepsis necrotizing enterocolitis hypertrophic pyloric stenosis congenital atresias/stenoses (esophagus to anus), malrotation with midgut volvulus functional obstruction secondary to Hirschsprung's disease or meconium ileus/plug.

No MeSH data available.


See case description
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MPX1242_synpic38234: See case description


Malrotation with Midgut Volvulus

Afiesimama BOA - MedPix (2007)

See case description
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=MPX1242&req=5

MPX1242_synpic38234: See case description

View Article: MedPix Image - MedPix Case

Affiliation: Uniformed Services University

ABSTRACT

Diagnosis: Malrotation with Midgut Volvulus

History: Nine day-old infant male who presents with bilious vomiting.

Findings: Plain film: The supine plain film of this infant at first glance demonstrates an apparent gastric outlet obstuction with a small amount of air within the proximal duodenum. The degree of gastric distention is variable, depending on the amount and frequency of vomiting. (Proximal gastric and duodenal dilatation can even be absent because of repeated emesis). There is a generalized paucity of gas distal to the apparent obstruction. The lack of distal bowel gas suggests that the mechanical obstruction is complete. Distention of gas-filled distal bowel is not seen, and there is no evidence of pneumatosis or pneumoperitoneum. These findings are relatively nonspecific, because in this supine film the duodenum is probably filled with fluid, thus making it invisible radiographically. The air in the distended stomach could erroneously suggest a gastric outlet obstruction. The "double-bubble" sign of duodenal atresia can also occur in malrotation but is not seen here. Upper GI Series: The first finding to note is the abnormal position of the nasogastric tube passing downward into an abnormally positioned jejunum. Before presenting the rest of the findings, it is important to know the normal anatomical features. The normal duodenojejunal junction, or Ligament of Treitz, is at the same level as the duodenal bulb - anterior to the left transverse process of L-1. The proximal jejunum is normally in the left abdomen. Note the persistent dilatation of the duodenal bulb and proximal duodenum, terminating in a distinctive conical shape. (The cone is hidden because of the overlying duodenal dilatation). There appears to be an obstruction of the third portion of the duodenum. In addition to this, the duodenum lies somewhat further to the right of the spine than normal (i.e. poor fixation secondary to the absence of the Ligament of Treitz). The mechanical obstruction is incomplete as evidenced by the passage of barium contrast beyond the point of obstruction into the jejunum. As the jejunum fills, it is seen to lie in an abnormal mid-abdominal and right-sided position. In this study, the "corkscrew" pattern of the small bowel (which is pathonogmonic of acute midgut volvulus) is absent. However, one can see the thickened folds of the valvulae conniventes. This is due to vascular obstruction and lymphatic engorgement. This is consistent with pathognomic spiraling of the small bowel around the superior mesenteric artery (i.e. vascular compromise can be assumed with certainty). Because of the mucosal edema, the corkscrew bowel segment may be difficult to see, especially at the most distal point of this contrast study. Finally, there is an oblique line formed by the narrowing of the contrast column. This is consistent with tight Ladd's bands.

Ddx: gastroesophageal reflux neonatal sepsis necrotizing enterocolitis hypertrophic pyloric stenosis congenital atresias/stenoses (esophagus to anus), malrotation with midgut volvulus functional obstruction secondary to Hirschsprung's disease or meconium ileus/plug.

No MeSH data available.