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Acute torsion of the small bowel mesentery is a diagnostically challenging cause of acute abdominal pain, which most commonly afflicts pediatric patients with midgut malrotation. We describe a case of mesenteric torsion in an adult patient that had manifested as acute abdominal pain. The patient had a remote history of prior abdominal surgery, presenting on multiple occasions with undiagnosed acute intermittent abdominal pain. Diagnosis of mesenteric torsion was made by contrast enhanced CT and the ailment was successfully treated with laparoscopic surgery without recurrence.

We report a case of midgut malrotation with volvulus in an adult diagnosed by ultrasonography, and we present the sonographic appearance of a specific sign of this uncommon anomaly: whirl-like encircling loops of bowel around the abnormal disposed mesenteric vessels.

Two cases of midgut malrotation are presented. Each had a clinical picture suggesting a possible intussusception. The radiographs also demonstrated findings suggestive of intussusception though these were subtle findings which could have suggested the correct diagnosis of malrotation.

A 23-year-old man with Aarskog's syndrome had Hirschspring's disease, midgut malrotation, a renal cyst, a cartilaginous projection of the pinna, geographic tongue, and dental anomalies. The family history, negative for these features, including several malignancies. Any or all of these features could be considered part of Aarskog's syndrome and may represent anomalies of neural crest development.

The history, physical examination, x-ray and operative findings and surgical procedures in eight patients with midgut malrotation producing extrinsic duodenal compression and volvulus are reviewed. Duodenal compression without volvulus is associated with a small mortality. Deaths from volvulus with bowel perforation may be prevented by prompt diagnosis and prompt operation.

Midgut malrotation is a surgical emergency usually seen in the first weeks of life. It presents with duodenal obstruction and bile emesis; the signs may be intermittent or minimal. The advantages and limitations of plain films, barium enema studies, and gastrointestinal studies were reviewed in 77 patients with malrotation; volvulus was seen in 65. Additional experience was gained from a questionnaire among members of the Society for Pediatric Radiology. Barium enema studies were preferred by 39 respondents. The upper gastrointestinal series was useful in defining extrinsic duodenal obstruction, but was difficult to interpret if the patient was asymptomatic when studied.

The plain film radiology in 45 cases of malrotation of the midgut are presented. The clinical features of the series are also reviewed. A triangular appearance of the proximal duodenum, the 'duodenal triangle', is described as an additional plain radiographic sign contributing to the early detection of malrotation.

Ultrasound was used to demonstrate the abnormal orientation of the mesenteric vessels in six cases of midgut malrotation. Five of these patients were known to have an abnormality of rotation before the ultrasound scan. In one patient malrotation was predicted from the ultrasound scan and confirmed by a barium study and at operation.

Malrotation of the intestine may become symptomatic in the older child and may manifest itself in atypical presentations. Older children may present with symptoms of less than 72 hours duration which are typical of acute duodenal obstruction. More frequently, however, the older child with malrotation will present with chronic abdominal pain with or without vomiting or chronic diarrhea. The diagnosis of malrotation should be considered in any child with intermittent abdominal pain, vomiting, diarrhea, or malabsorption. Surgical intervention is curative and should be implemented as soon as possible after the diagnosis is made.

This paper describes a simple and effective fluoroscopic technique that remarkably improves diagnostic accuracy when evaluating vomiting newborns. The technique also minimizes the time of the examination and the radiation dose to the patient and radiology personnel. Several examples are presented illustrating the superiority of gloved hand or nonopaque compression technique to conventional contrast radiography, emphasizing babies with pyloric stenosis and midgut malrotation. The technical limitations and diagnostic pitfalls of conventional contrast modalities are compared to the highly diagnostic images obtained with manual compression fluoroscopy. All of the classic radiographic signs of pyloric stenosis can be mimicked by antral spasm or pylorospasm. Gloved hand compression overcomes antral spasm and clearly shows the true length and diameter of the pyloric canal in these two conditions. Malposition of the duodenojejunal junction is the only consistently diagnostic sign of midgut malrotation. Nonfixation of the duodenojejunal junction can be competently assessed by compression fluoroscopy, confirming malrotation and midgut volvulus simultaneously and bringing the patient to operation much sooner than with less precise conventional techniques. Gloved hand compression technique also evaluates stenotic areas in the upper gastrointestinal tract, distinguishing spasm from organic marrowing and clearly identifying those which need surgical intervention. Facilitating intubation of the duodenum is a final contribution of compression fluoroscopy.

Computed tomography (CT) of the pancreas, with its excellent display of peripancreatic anatomy, allows visualization of the major vessels entering the mesenteric root. In scans of the normal upper abdomen obtained at or just below the level of the uncinate process of the pancreas, the proximal superior mesenteric vein (SMV) easily can be identified lying on the right ventral aspect of the superior mesenteric artery (SMA). The authors have observed a characteristic abnormality in this normal vascular arrangement on CT scans of the pancreas in three adult patients with suspected chronic pancreatitis who were subsequently proved to have midgut malrotation. They called this the SMV rotation sign and believe that its detection even on CT scans limited to the level of the pancreas should alert the radiologist to the presence of a midgut malrotation that may have been unsuspected.

A case of congenital anomalies of rotation and fixation of the midgut with volvulus in an adult is described. The diagnosis of volvulus was based on the characteristic angiographic appearance or “barber pole sign.” Demonstration of vascular obstruction secondary to volvulus led to successful surgical correction, thus avoiding fatal complications.

The details of 2 adult patients are reported who presented with abdominal colic and were found to have malrotation of the midgut. However, in both cases the clinical presentation resulted from the association of the malrotation with a persistent Meckel's diverticulum. This particular association does not appear to have keen stressed or commented upon before.

Top of pageAbstract The introduction of feeds after correction of a midgut malrotation is usually uneventful but may be difficult in a small number of cases. The nature or the intrauterine migration defect is unknown. We assessed small intestinal motor activity manometrically in five children (mean age 13.6 mths) with persistent feeding problems after correction at a mean time of 13.0 mths after surgery. Two groups were noted. Four children with persistent vomiting did not tolerate oral feeds. All of these had a second surgical procedure attempting to relieve an obstruction (2 a pyloromyotomy, 1 an ileocaecal resection, 1 an ileostomy) but continued to have symptoms. Tnree had abnormal small intestinal motility, one no activity, one slow Phase III pressure wave frequency with short Phase III duration, and one non-propagated Phase III complexes with a low motility index (MI). One child (number 5) had severe diarrhoea after feeds due to a short bowel syndrome following an ileal resection after a volvulus. This child had a low motility index in Phase III. Tnese data show that a pattern of motor activity similar to that seen in intestinal neuropathic disorders is present in these patients. We speculate that the malrotation is secondary to a neuropathic disorder present during early foetal development in some patients.