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Virtual Pediatric Hospital: Paediapaedia: Malrotation and Midgut Volvulus Paediapaedia: Gastrointestinal Diseases

Malrotation and Midgut Volvulus

Michael P. D'Alessandro, M.D.
Peer Review Status: Internally Peer Reviewed


Clinical Presentation:
Sudden onset of bilious vomiting in a neonate. Malrotation with volvulus and or duodenal bands must be the first thought in a child who presents with symptoms of duodenal obstruction. Forty percent of patients with malrotation present in the first week and 80% present by the first month. Rarely this can present in older children, and when it does the symptoms are often intermittent.

Etiology/Pathophysiology:
In a normally rotated individual, the small bowel mesentary is broad based and extends from the left upper quadrant to the right iliac fossa. Malrotation is an abnormal or incomplete rotation of the embryonic midgut. In a malrotated individual, the small bowel mesentary is shortened and the ligament of Treitz and cecum are poorly fixed. This predisposes the patient to the development of midgut volvulus, or twisting, around the superior mesenteric artery which leads to bowel ischemia and necrosis.

Pathology:
Not applicable

Imaging Findings:
There are three abdominal plain film patterns associated with malrotation and midgut volvulus : (1) normal, (2) duodenal obstruction, and (3) small bowel obstruction. The diagnosis is established via an upper GI exam which will demonstrate the duodenojejunal junction displaced from its normal position on the left of the spine at the level of the duodenal bulb to a position to the right of the spine, and a spiral corkscrew appearance of the duodenum and proximal jejunum which illustrates the volvulus. Duodenal obstruction from the midgut volvulus may be complete.

DDX:
High Bowel Obstruction

References:

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