Purpose or Case Report: Intestinal rotation abnormality (IRA) can lead to catastrophic events from midgut volvulus. In a child that presents with bilious vomiting, urgent surgery should be performed. Ladd’s surgery is associated with complications in 10% to 20% of the patients. In this review we will show that in selected asymptomatic children with IRA, imaging can help decide if observation should be considered rather than surgery.
Methods & Materials:
We reviewed upper gastrointestinal contrast studies, small bowel follow through contrast studies (SBFT), and colon enemas of children with a diagnosis of IRA who had surgery. We evaluated location of the duodenal jejunal junction (DJJ), position of the duodenum in the lateral view, and the anatomy of the colon. Location of the DJJ to the right of the left pedicle on the anterioposterior view or anterior in the lateral view was defined as IRA. We evaluated three types of IRA based on current literature: nonrotation (entire colon in the left abdomen, cecum in the left lower quadrant and the small bowel in the right abdomen), atypical malrotation (DJJ between midline and left pedicle), and typical malrotation (IRA that cannot be defined as nonrotation or atypical malrotation).
Results:
We will present an imaging algorithm for evaluation of malrotation and show imaging findings of all types of IRA as well as challenging cases. We will show cases with nonrotation when there was no need for surgery and other cases when Ladd bands were found. We will show cases of atypical malrotation. We found that if the duodenum is posterior and the entire colon is normal, the mesenteric root is broad and there is no need for surgery. We will also show indeterminate cases, when laparoscopy was necessary.
We will show how anatomy of the colon helps to define the types of IRA. We will show cases where SBFT did not demonstrate the entire colon and was misleading. Enema should, therefore, be considered to evaluate the anatomy of the colon for definitive diagnosis.
Conclusions: We suggest considering a more stringent definition of atypical malrotation when there is also posterior position of the duodenum and normal colon. In asymptomatic children, especially at older ages, findings of nonrotation or atypical malrotation can provide an option for observation rather than surgery.