Download Mid-Gut Volvulus Identified by Pediatric Emergency Ultrasonography

The Journal of Emergency Medicine, Vol. 45, No. 5, pp. e173–e174, 2013
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http://dx.doi.org/10.1016/j.jemermed.2013.05.048
Visual Diagnosis
in Emergency Medicine
MID-GUT VOLVULUS IDENTIFIED BY PEDIATRIC EMERGENCY
ULTRASONOGRAPHY
Adam Brand Sivitz, MD*† and Rachel Lyons, DNP, CPNP-PC/AC*‡
*Department of Emergency Medicine, Newark Beth Israel Medical Center, Children’s Hospital of New Jersey, Newark, New Jersey, †New
Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, New Jersey, and ‡Rutgers University, College of Nursing,
Newark, New Jersey
Reprint Address: Adam Brand Sivitz, MD, Department of Emergency Medicine, Newark Beth Israel Medical Center, Children’s Hospital of New
Jersey, 201 Lyons Avenue, Newark, NJ 07112
was no passage of barium past the second portion of the
duodenum on an upper gastrointestinal (GI) series. Intraoperatively, the volvulus was corrected, repositioned, and
did not require any bowel resection.
CASE REPORT
A 3-day-old full-term male infant presented to the
emergency department (ED) after a 12-h history of decreased feeding, bloody stools 2, and emesis that
was reportedly white but becoming yellow tinged. Vital
signs at triage were as follows: temperature 36.1 C,
heart rate 142 beats/min, respiratory rate 40 breaths/
min, and pulse oximetry 99% on room air. Physical examination revealed a term infant with a distended abdomen who cried on abdominal palpation. Bedside
sonography by a pediatric emergency physician revealed
the superior mesenteric artery (SMA) to the right of the
superior mesenteric vein (Figure 1), a whirlpool-like
vascular structure (Figure 2), and no duodenum between
the superior mesenteric artery and aorta (Figure 3).
DISCUSSION
Midgut volvulus is a life-threatening emergency. Children can present with acute midgut volvulus at any age,
Diagnosis: Malrotation with Midgut Volvulus
Pediatric surgery consultation was obtained immediately.
Radiology found similar findings on ultrasound, and there
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Figure 1. Transverse midline abdominal view with a highfrequency linear probe of the superior mesenteric artery
(left arrow) to the anatomic right of the superior mesenteric
vein (right arrow) using color Doppler.
RECEIVED: 14 December 2012;
ACCEPTED: 1 May 2013
e173
e174
A. B. Sivitz and R. Lyons
Figure 2. Superior mesenteric vein (arrows) wrapping around
the superior mesenteric artery.
Figure 3. Duodenum passing anterior to the superior mesenteric artery (SMA). Ao = aorta; D = duodenum; G = gastrum.
*SMA. Arrow, third part of the duodenum.
although the vast majority of patients are younger than
1 year (1). During embryogenesis, the bowel normally rotates counterclockwise 270 degrees around the SMA. In
bowel that is malrotated, the rotation is not normal,
with a resulting shortened mesenteric pedicle predisposing to midgut volvulus. In addition to the torsed bowel,
there are often obstructing fibrous peritoneal bands
(Ladd bands) that cross from the malpositioned cecum
to the lateral peritoneal gutter. Diagnosis is classically
confirmed by upper GI series, but can also be evaluated
by ultrasound (2).
In normally rotated patients, the superior mesenteric
vein (SMV) is positioned to the right of the SMA. In malrotation, the SMV may appear anterior, or more definitively, to the left of the SMA. The ‘‘whirlpool’’ sign
refers to the sonographic appearance of the SMV wrapping around the axis of the SMA in volvulus when using
color Doppler sonography (3). Finally, the normal position of the third part of the duodenum lies between the
SMA and the aorta. It has been suggested with malrotation that bowel will not be seen in this position
sonographically (4). In this case, prompt recognition using bedside sonography helped to facilitate early diagnosis and surgical consultation for midgut volvulus.
REFERENCES
1. Torres AM, Ziegler MM. Malrotation of the intestine. World J Surg
1993;17:326–31.
2. Applegate KE. Evidence-based diagnosis of malrotation and volvulus. Pediatr Radiol 2009;39(Suppl. 2):S161–3.
3. Pracros JP, Sann L, Genin G, et al. Ultrasound diagnosis of midgut
volvulus: the ‘‘whirlpool’’ sign. Pediatr Radiol 1992;22:18–20.
4. Yousefzadeh DK, Kang L, Tessicini L. Assessment of retromesenteric position of the third portion of the duodenum: an US feasibility
study in 33 newborns. Pediatr Radiol 2010;40:1476–84.
SUPPLEMENTARY DATA
Supplementary data associated with this article can be
found, in the online version, at http://dx.doi.org/10.
1016/j.jemermed.2013.05.048.
Streaming video: One brief real-time video clip that accompanies this article is available in streaming video at www.journals.elsevierhealth.com/periodicals/jem. Click on
Video Clip 1.