Purpose or Case Report: To evaluate the impact of an “ultrasound-first” pathway for suspected midgut malrotation/volvulus on diagnostic timeliness and outcomes.
Methods & Materials: An US-first protocol was implemented as a quality improvement initiative, with targeted ultrasound as the first-line investigation and fluoroscopic upper gastrointestinal contrast series (UGC) reserved for inconclusive cases. A pre- and post-implementation study was conducted over six-months. Infants ≤1 year with clinical suspicion of malrotation/volvulus were included. UGC was reserved for inconclusive US findings. Primary outcomes were time-to-diagnosis, radiation dose, and cost. Secondary outcomes included diagnostic accuracy and bowel necrosis rates.
Results: The US-first protocol was applied in 33 infants (20 males; median age 30 days, range 3–395), reducing median time-to-diagnosis from 48 to 18 minutes (p<0.001), eliminating radiation exposure (median: 0.3 mSv in a pre-implementation group of 31 infants), and saving approximately SGD $2,925 per study cycle. Ultrasound achieved 97% diagnostic accuracy with 100% specificity for midgut volvulus, detecting three (9%) cases of malrotation, including two with volvulus. Further UGC was performed in three patients—one due to suboptimal ultrasound and two at surgical discretion. Five critically ill or ventilated infants underwent bedside ultrasound, demonstrating the protocol’s accessibility. Ultrasound also identified alternative diagnoses of pyloric stenosis in two patients. No cases of bowel necrosis occurred.
Conclusions: Our transition to an “US-first” workflow for suspected malrotation is safe, accurate, and time-efficient. It minimizes radiation, accelerates diagnosis, and optimizes resource use. UGC remains a valuable complementary tool when US is inconclusive or non-diagnostic. Successful implementation requires close multidisciplinary collaboration, sustained sonographer training and regular audits.