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Midgut Volvulus
Steven J. Kraus, MD
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Clinical Issues

          • Diagnostic Checklist

            TERMINOLOGY

            • Definitions

              • Ligament of Treitz: Suspends duodenojejunal junction (DJJ), defines normal duodenal rotation
              • Malrotation: Abnormal rotation & fixation of small bowel (SB) mesentery that can lead to complications, including
                • Midgut volvulus (MGV): Abnormal twisting of SB about superior mesenteric artery (SMA) that can lead to bowel obstruction & ischemia/necrosis
                • Ladd bands: Abnormal, fibrous peritoneal bands that can also cause duodenal obstruction
              • Bilious vomiting: Green/yellow vomit, typically from obstruction of duodenum distal to ampulla of Vater

            IMAGING

            • General Features

              • Radiographic Findings

                • Fluoroscopic Findings

                  • Ultrasonographic Findings

                    • CT Findings

                      • Imaging Recommendations

                        DIFFERENTIAL DIAGNOSIS

                          PATHOLOGY

                          • General Features

                            • Microscopic Features

                              CLINICAL ISSUES

                              • Presentation

                                • Demographics

                                  • Natural History & Prognosis

                                    • Treatment

                                      DIAGNOSTIC CHECKLIST

                                      • Consider

                                        • Image Interpretation Pearls

                                          Selected References

                                          1. Nguyen HN et al: Transition to ultrasound as the first-line imaging modality for midgut volvulus: keys to a successful roll-out. Pediatr Radiol. 51(4):506-15, 2021
                                          2. Nguyen HN et al: Untwisting the complexity of midgut malrotation and volvulus ultrasound. Pediatr Radiol. 51(4):658-68, 2021
                                          3. Strouse PJ: Ultrasound for malrotation and volvulus: has the time come? Pediatr Radiol. 51(4):503-5, 2021
                                          4. Expert Panel on Pediatric Imaging. et al: ACR Appropriateness Criteria® vomiting in infants. J Am Coll Radiol. 17(11S):S505-15, 2020
                                          5. Hosokawa T et al: Use of ultrasound findings to predict bowel ischemic changes in pediatric patients with intestinal volvulus. J Ultrasound Med. 39(4):683-92, 2020
                                          6. Nguyen HN et al: Time-driven activity-based cost comparison of three imaging pathways for suspected midgut volvulus in children. J Am Coll Radiol. 17(12):1563-70, 2020
                                          7. Bartholmot C et al: Prenatal diagnosis of antenatal midgut volvulus: specific ultrasound features. Prenat Diagn. 39(1):16-25, 2019
                                          8. Garcia AM et al: A multi-institutional case series with review of point-of-care ultrasound to diagnose malrotation and midgut volvulus in the pediatric emergency department. Pediatr Emerg Care. 35(6):443-7, 2019
                                          9. Carroll AG et al: Comparative effectiveness of imaging modalities for the diagnosis of intestinal obstruction in neonates and infants: a critically appraised topic. Acad Radiol. 23(5):559-68, 2016
                                          10. Drewett M et al: The burden of excluding malrotation in term neonates with bile stained vomiting. Pediatr Surg Int. 32(5):483-6, 2016
                                          11. Dumitriu DI et al: Ultrasound of the duodenum in children. Pediatr Radiol. 46(9):1324-31, 2016
                                          12. Horsch S et al: Volvulus in term and preterm infants - clinical presentation and outcome. Acta Paediatr. 105(6):623-7, 2016
                                          13. Shrimal PK et al: Midgut volvulus with whirlpool sign. Clin Gastroenterol Hepatol. 14(2):e13, 2016
                                          14. Abdelhafeez AH et al: The risk of volvulus in abdominal wall defects. J Pediatr Surg. 50(4):570-2, 2015
                                          15. Coe TM et al: Small bowel volvulus in the adult populace of the United States: results from a population-based study. Am J Surg. 210(2):201-10.e2, 2015
                                          16. Kargl S et al: Volvulus without malposition--a single-center experience. J Surg Res. 193(1):295-9, 2015
                                          17. Koong JK et al: Midgut volvulus: a rare cause of intestinal obstruction in adults. ANZ J Surg. 88(4):E348-9, 2015
                                          18. Mitsunaga T et al: Risk factors for intestinal obstruction after Ladd procedure. Pediatr Rep. 7(2):5795, 2015
                                          19. Nakagawa T et al: A case of fetal intestinal volvulus without malrotation causing severe anemia. Jpn Clin Med. 6:1-3, 2015
                                          20. Raske ME et al: ACR Appropriateness Criteria Vomiting in Infants up to 3 Months of Age. J Am Coll Radiol. 12(9):915-22, 2015
                                          21. Shah MR et al: Volvulus of the entire small bowel w1th normal bowel fixation simulating malrotation and midgut volvulus. Pediatr Radiol. 45(13):1953-6, 2015
                                          22. Marine MB et al: Imaging of malrotation in the neonate. Semin Ultrasound CT MR. 35(6):555-70, 2014
                                          23. Nehra D et al: Intestinal malrotation: varied clinical presentation from infancy through adulthood. Surgery. 149(3):386-93, 2011
                                          24. Taylor GA: CT appearance of the duodenum and mesenteric vessels in children with normal and abnormal bowel rotation. Pediatr Radiol. 41(11):1378-83, 2011
                                          25. Lampl B et al: Malrotation and midgut volvulus: a historical review and current controversies in diagnosis and management. Pediatr Radiol. 39(4):359-66, 2009
                                          26. Yousefzadeh DK: The position of the duodenojejunal junction: the wrong horse to bet on in diagnosing or excluding malrotation. Pediatr Radiol. 39 Suppl 2:S172-7, 2009
                                          27. Patino MO et al: Utility of the sonographic whirlpool sign in diagnosing midgut volvulus in patients with atypical clinical presentations. J Ultrasound Med. 23(3):397-401, 2004
                                          28. Strouse PJ: Disorders of intestinal rotation and fixation ("malrotation"). Pediatr Radiol. 34(11):837-51, 2004
                                          29. Chao HC et al: Sonographic features related to volvulus in neonatal intestinal malrotation. J Ultrasound Med. 19(6):371-6, 2000
                                          30. Long FR et al: Radiographic patterns of intestinal malrotation in children. Radiographics. 16(3):547-56; discussion 556-60, 1996
                                          Related Anatomy
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                                          Related Differential Diagnoses
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                                          References
                                          Tables

                                          Tables

                                          KEY FACTS

                                          • Terminology

                                            • Imaging

                                              • Top Differential Diagnoses

                                                • Clinical Issues

                                                  • Diagnostic Checklist

                                                    TERMINOLOGY

                                                    • Definitions

                                                      • Ligament of Treitz: Suspends duodenojejunal junction (DJJ), defines normal duodenal rotation
                                                      • Malrotation: Abnormal rotation & fixation of small bowel (SB) mesentery that can lead to complications, including
                                                        • Midgut volvulus (MGV): Abnormal twisting of SB about superior mesenteric artery (SMA) that can lead to bowel obstruction & ischemia/necrosis
                                                        • Ladd bands: Abnormal, fibrous peritoneal bands that can also cause duodenal obstruction
                                                      • Bilious vomiting: Green/yellow vomit, typically from obstruction of duodenum distal to ampulla of Vater

                                                    IMAGING

                                                    • General Features

                                                      • Radiographic Findings

                                                        • Fluoroscopic Findings

                                                          • Ultrasonographic Findings

                                                            • CT Findings

                                                              • Imaging Recommendations

                                                                DIFFERENTIAL DIAGNOSIS

                                                                  PATHOLOGY

                                                                  • General Features

                                                                    • Microscopic Features

                                                                      CLINICAL ISSUES

                                                                      • Presentation

                                                                        • Demographics

                                                                          • Natural History & Prognosis

                                                                            • Treatment

                                                                              DIAGNOSTIC CHECKLIST

                                                                              • Consider

                                                                                • Image Interpretation Pearls

                                                                                  Selected References

                                                                                  1. Nguyen HN et al: Transition to ultrasound as the first-line imaging modality for midgut volvulus: keys to a successful roll-out. Pediatr Radiol. 51(4):506-15, 2021
                                                                                  2. Nguyen HN et al: Untwisting the complexity of midgut malrotation and volvulus ultrasound. Pediatr Radiol. 51(4):658-68, 2021
                                                                                  3. Strouse PJ: Ultrasound for malrotation and volvulus: has the time come? Pediatr Radiol. 51(4):503-5, 2021
                                                                                  4. Expert Panel on Pediatric Imaging. et al: ACR Appropriateness Criteria® vomiting in infants. J Am Coll Radiol. 17(11S):S505-15, 2020
                                                                                  5. Hosokawa T et al: Use of ultrasound findings to predict bowel ischemic changes in pediatric patients with intestinal volvulus. J Ultrasound Med. 39(4):683-92, 2020
                                                                                  6. Nguyen HN et al: Time-driven activity-based cost comparison of three imaging pathways for suspected midgut volvulus in children. J Am Coll Radiol. 17(12):1563-70, 2020
                                                                                  7. Bartholmot C et al: Prenatal diagnosis of antenatal midgut volvulus: specific ultrasound features. Prenat Diagn. 39(1):16-25, 2019
                                                                                  8. Garcia AM et al: A multi-institutional case series with review of point-of-care ultrasound to diagnose malrotation and midgut volvulus in the pediatric emergency department. Pediatr Emerg Care. 35(6):443-7, 2019
                                                                                  9. Carroll AG et al: Comparative effectiveness of imaging modalities for the diagnosis of intestinal obstruction in neonates and infants: a critically appraised topic. Acad Radiol. 23(5):559-68, 2016
                                                                                  10. Drewett M et al: The burden of excluding malrotation in term neonates with bile stained vomiting. Pediatr Surg Int. 32(5):483-6, 2016
                                                                                  11. Dumitriu DI et al: Ultrasound of the duodenum in children. Pediatr Radiol. 46(9):1324-31, 2016
                                                                                  12. Horsch S et al: Volvulus in term and preterm infants - clinical presentation and outcome. Acta Paediatr. 105(6):623-7, 2016
                                                                                  13. Shrimal PK et al: Midgut volvulus with whirlpool sign. Clin Gastroenterol Hepatol. 14(2):e13, 2016
                                                                                  14. Abdelhafeez AH et al: The risk of volvulus in abdominal wall defects. J Pediatr Surg. 50(4):570-2, 2015
                                                                                  15. Coe TM et al: Small bowel volvulus in the adult populace of the United States: results from a population-based study. Am J Surg. 210(2):201-10.e2, 2015
                                                                                  16. Kargl S et al: Volvulus without malposition--a single-center experience. J Surg Res. 193(1):295-9, 2015
                                                                                  17. Koong JK et al: Midgut volvulus: a rare cause of intestinal obstruction in adults. ANZ J Surg. 88(4):E348-9, 2015
                                                                                  18. Mitsunaga T et al: Risk factors for intestinal obstruction after Ladd procedure. Pediatr Rep. 7(2):5795, 2015
                                                                                  19. Nakagawa T et al: A case of fetal intestinal volvulus without malrotation causing severe anemia. Jpn Clin Med. 6:1-3, 2015
                                                                                  20. Raske ME et al: ACR Appropriateness Criteria Vomiting in Infants up to 3 Months of Age. J Am Coll Radiol. 12(9):915-22, 2015
                                                                                  21. Shah MR et al: Volvulus of the entire small bowel w1th normal bowel fixation simulating malrotation and midgut volvulus. Pediatr Radiol. 45(13):1953-6, 2015
                                                                                  22. Marine MB et al: Imaging of malrotation in the neonate. Semin Ultrasound CT MR. 35(6):555-70, 2014
                                                                                  23. Nehra D et al: Intestinal malrotation: varied clinical presentation from infancy through adulthood. Surgery. 149(3):386-93, 2011
                                                                                  24. Taylor GA: CT appearance of the duodenum and mesenteric vessels in children with normal and abnormal bowel rotation. Pediatr Radiol. 41(11):1378-83, 2011
                                                                                  25. Lampl B et al: Malrotation and midgut volvulus: a historical review and current controversies in diagnosis and management. Pediatr Radiol. 39(4):359-66, 2009
                                                                                  26. Yousefzadeh DK: The position of the duodenojejunal junction: the wrong horse to bet on in diagnosing or excluding malrotation. Pediatr Radiol. 39 Suppl 2:S172-7, 2009
                                                                                  27. Patino MO et al: Utility of the sonographic whirlpool sign in diagnosing midgut volvulus in patients with atypical clinical presentations. J Ultrasound Med. 23(3):397-401, 2004
                                                                                  28. Strouse PJ: Disorders of intestinal rotation and fixation ("malrotation"). Pediatr Radiol. 34(11):837-51, 2004
                                                                                  29. Chao HC et al: Sonographic features related to volvulus in neonatal intestinal malrotation. J Ultrasound Med. 19(6):371-6, 2000
                                                                                  30. Long FR et al: Radiographic patterns of intestinal malrotation in children. Radiographics. 16(3):547-56; discussion 556-60, 1996