Purpose or Case Report: Common causes of bowel obstruction (BO) in infants and children include appendicitis, adhesions, intussusception, inguinal hernia, midgut volvulus, and Meckel's diverticulum, for which the mnemonic "AIM” is used. We present uncommon causes of BO in infants and children and review the clinical presentation, imaging findings, and surgical diagnoses.
Methods & Materials: The hospital database was searched for cases of BO in infants and children under age 10 years during the years 2013-2017, excluding appendicitis, post-surgical adhesions, intussusception, inguinal hernia, midgut volvulus, and Meckel's diverticulum. Patient age, comorbidities, clinical presentation (including duration of symptoms), imaging findings, and surgical diagnoses were reviewed.
Results: Nine uncommon causes of BO were identified and included cecal volvulus (2 cases), primary midgut volvulus with normal bowel fixation (1 case), isolated ileal volvulus (1 case), congenital bands (2 cases), internal hernia (1 case), and radiolucent foreign bodies (2 cases). Patients ranged in age from 10 weeks to 11 years. Symptom duration was variable. Underlying comorbidities were present in 2 cases (Down’s syndrome and Cornelia de Lange syndrome). Plain abdominal radiographs were available in all cases. Four patients underwent computed tomography, 2 patients underwent upper gastrointestinal series, and 1 underwent a contrast enema. Abdominal radiographs in cecal volvulus demonstrated right sided and midline colonic distension. In both the case of closed-loop obstruction with bands and primary volvulus, abdominal films demonstrated a midline mass containing air and displacing the colon laterally. The remainder of cases presented with dilated stacked small bowel loops indistinguishable from other causes of small bowel obstruction. Plain film findings of pneumatosis mimicking necrotizing enterocolitis (NEC) were present in an infant with isolated ileal volvulus. CT was the imaging modality most likely to aid in diagnosis but did not affect management. All patients underwent emergent surgery.
Conclusions: We discuss the unusual and often confusing imaging findings in uncommon causes of BO in infants and children. In some cases, radiographs mimic NEC, resulting in diagnostic delay. Awareness of characteristic plain films findings, such as those seen in cecal volvulus, may aid in diagnosis. In acutely ill patients, additional imaging may delay prompt surgical intervention.