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Joseph Junewick, MD FACR
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Malrotation

Case Detail

Anatomy: Gastrointestinal
Borders
Heather Borders, MD
Diagnostic Category: Developmental or Congenital
Created: over 7 years ago
Updated: over 7 years ago
Tags: PEDS
Modality/Study Types: CT
Activities:
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History

Five year old female with a history of intermittent severe abdominal pain.


Case Images


Diagnosis

Malrotation

Findings

CT revealed inversion of the normal SMA and SMV relationship. The colon was primarily on the left side of the abdomen and the small bowel on the right side. The duodenum could not be followed passing behind the SMA to the left of the spine.

A follow up upper GI confirmed malrotation; the duodenum did not cross midline and the cecum was midline to right upper quadrant in position. The cecum was mobile to palpation.

Discussion

Normal bowel development involves a total counterclockwise rotation of 270 degrees. The process can be interrupted at any point. Malrotation can be used to refer to the spectrum of abnormality that can result from interruption of this normal process.

In patients with normal positioning of bowel there is a long mesentery from the duodenojejunal junction to the cecum. When there is maloration the mesentery is typically short and prone to twisting i.e. volvulus.

Malrotation may be associated with other abnormalities, such as cloacal extrophy, trisomy 21 and Hirschprung disease to name a few.

Imaging findings are multiple and include; abnormal duodenojejunal junction that is not at the level of the pylorus and to the left of the left pedicle, non retroperitoneal position of the duodenum on lateral images, inversion of SMA and SMV relationship on cross section, abnormal position of the colon. There are a variety of normal variants and subtleties to the diagnosis. Many of these are reviewed in available articles and texts.

Reference

Intestinal Malrotation in Children: A Problem-solving Approach to the Upper Gastrointestinal Series1
Kimberly E. Applegate

Caffeys Pediatric Diagnostic Imaging, pp. 2106-2114.



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