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Age: 1 week (term)

Sex: Male

Indication: Bilious vomiting

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Case #6


Findings

  • Borderline dilated loops of bowel in the left hemiabdomen with relative paucity of bowel gas in the right hemiabdomen
  • No evidence of free intraperitoneal air
  • No acute findings in the chest


Diagnosis

  • Midgut volvulus

Sample Report

Nonspecific bowel gas pattern with borderline dilated loops of bowel in the left hemiabdomen with relative paucity of bowel gas in the right hemiabdomen. Consider upper GI series for further evaluation.

No evidence of free intraperitoneal air.

No abnormal intraabdominal mass effect or calcifications.

No acute findings in the chest.


Discussion

  • Most children who experience midgut volvulus will present in the first month of life
  • The classic presentation is bilious emesis (unlike pyloric stenosis which presents with nonbilious emesis)
  • Fluoroscopic upper GI study is the diagnostic test of choice, which in positive cases typically shows both abnormal rotation and evidence of obstruction
    • Abnormal duodenal rotation is defined by an abnormally inferior and/or right position of the ligament of Treitz (should normally be just to the left of the spine at the level of the duodenal bulb, which is typically at the level of the L1 pedicles)
    • Obstruction often takes a corkscrew appearance as the involved bowel twists on itself over a narrow mesenteric root


Images

Red arrow: corkscrew appearance of the distal duodenum with the ligament of Treitz to the right of the spine on this patient's upper GI evaluation.

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