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Virtual Pediatric Hospital: Correlapaedia - a Correlative Encyclopedia of Pediatric Imaging, Surgery, and Pathology: Case 4

Correlapaedia - a Correlative Encyclopedia of Pediatric Imaging, Surgery, and Pathology

Case 4

Michael P. D'Alessandro, M.D.,
Steven J. Fishman, M.D.,
Deborah E. Schofield, M.D.

Peer Review Status: Internally Peer Reviewed
Chief Complaint:
Two day old former 36 week premature female with bilious vomiting.

Clinical History:
The patient was a 36 hour old former 36 week premature female and was the product of a twin gestation. She developed bilious emesis and bilious aspirates were subsequently returned from her nasogastric tube.

Clinical Physical Exam:
Aside from bile stained aspirates, the clinical exam was unremarkable

Clinical Labs:

Clinical Differential Diagnosis:
Malrotation and midgut volvulus, duodenal atresia

Imaging Findings:
An upper GI exam was performed on the second day of life to rule out malrotation and midgut volvulus. The exam convincingly demonstrated the presence of malrotation and midgut volvulus.

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Imaging Differential Diagnosis:
Malrotation with midgut volvulus.

Operative Findings:
The patient was taken emergently to the operating room. Via a transverse supraumbilical incision, the abdomen was entered. Intestinal malrotation with midgut volvulus was noted. The midgut was dusky but not necrotic, with the entire midgut being twisted around a single narrow mesentery. The midgut was detorsed in a counter-clockwise direction 360 degrees. The midgut then pinked up. A Ladd's procedure was performed, placing the cecum and ascending colon in the left lower quadrant adjacent to the descending colon, and the duodenum was placed vertically with the proximal small intestine placed into the right side of the abdomen. An incidental appendectomy was performed.

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Pathological Findings:

Final Diagnosis:
Malrotation and Midgut Volvulus

Follow-up and Prognosis:
The patient had an uncomplicated post-operative course.

Similar Cases:
Case 6, Case 14, Case 20, Case 23


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