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This is Pediatrics week two case number

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three and the topic is malrotation.

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So the image that you can see here is the

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initial image of a fluoroscopic upper GI

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exam in this exam is frequently performed for

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patients with vomiting patients who are going

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to have a gastrostomy tube placed by the

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surgeons or Interventional Radiologists and it's

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to identify the course and caliber of the proximal small

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bowel. If you recall from embryology at around

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eight weeks or so of gestation the

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bowel exits the embryo fetal

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abdomen and rotates 270 degrees

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before returning to the abdomen and

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if any thing in gestation interrupts that

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process arrests the rotation of the

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bowel,

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Then you will have some degree of malrotation. So

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there's the fully rotated bowel, which

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is normal. There's the completely unrotated bowel

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which we call non-rotation and then

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there is every variation in between. So malrotation

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is a very broad spectrum

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of disease some of which is quite dramatically abnormal

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some of which is very subtle. And so the

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radiologist needs to be prepared to identify the signs

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of a normal exam and where there's deviation. So I'm

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just going to

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Scroll us through this fluoroscopic exam

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when possible the contrast is administered by

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mouth or you know, maybe by drinking

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through a straw or a bottle if it's an infant. This

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is an older child here.

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And you can see it passing down the esophagus. We

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usually start the exam in lateral position to obtain

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some lateral column of pacification of

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the esophagus and then we switch to a frontal position and you

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can see the contrasting coursing down the midline. These are

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normal peristaltic waves. So this narrowing is transient

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that's not disease and you can see it coming all

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the way down and entering the stomach. I'm just gonna continue to

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scroll through once you've obtained your esophageal Imaging you're

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gonna of course turn to the stomach some people might even obtain their

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gastric and duodenal images first and

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then go back and do the esophagus at the end.

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Here you can see contrast filling the stomach. This is

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a lateral view. You can see the vertebral column on one

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side of the image. And this is helpful to identify the

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contrast as it goes into the duodenum and you'll recall most

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of the duodenum is retroperitoneal. So we need to

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see that contrast not merely go into the duodenum from

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an AP point of view where it goes to the right but also

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posteriorly into the retroperitoneal

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Abdomen and so here we can see.

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Contrast moving to the antral portion

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of the stomach. This is the first little passage

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of contrast into the duodenum. And if

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you're really eagle-eyed and you're paying

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attention, you can see very faintly a tiny

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little slip of contrast moving in that

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line right across there into the duodenum. We're

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going to progress through the exam now, we can see a little bit more contrast

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has moved into the duodenum and it's coming

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up into the third portion which is posterior here.

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It's moving down and then we should see that contrast

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after it's descended come back up.

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This is the point at which it's crossing the midline hopefully over

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to the left hemiabdomen. However, when

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we flip the patient back

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To AP position. We notice the contrast hasn't moved across

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the midline. It went posterior on the lateral View and it

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stayed in the right side of the abdomen. So

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we continue to follow it but this is a little bit of an atypical

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configuration right from the get-go. We're going to

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continue to follow that contrast and now we see it starting to

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make what looks like a normal C Loop

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of the duodenum. Okay, that's reassuring maybe it

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just took a little time to get there. We do have a phenomenon called

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a redundant or wandering duodenum, but we

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still need to watch it because our rule of thumb is we want contrast to

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come down through the duodenum sweep back

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up to a level that's to the left of

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the vertebral column and as high as the

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gastric Outlet, so we're not there yet. We're gonna

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keep on watching that contrast. This is an oblique view

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notice how the ribs on the right are

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at a quite different angle than the ribs on the left. So even

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though you might be asking yourself has my

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contrast cross to the left of the vertebral column. Don't trust

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the image. If it's oblique, you need

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a true AP image. So we need to get back to

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the point where we've got our ribs more symmetrically aligned

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like this image here vertebral column in the

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center. And with this positioning, there's no question that our

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contrast has stayed on the right. We're going

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to keep watching that contrast and here we are.

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Lateral view showing that it descended but it

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never really came back up it stayed down

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it stayed to the right and these are all the signs of

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malrotation. I'm going to progress through the exam back to

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AP View and you can see more contrast on

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the right multiple loops on the right. We're not

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seeing any small bowel Crossing back over to the left.

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And this is just getting confirmed more and

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more with this type of exam this clear. You

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don't really need to identify the position of the cecum to

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call it Mal rotation. You already know but it

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is nice to follow through just to be able to identify where

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that cecum is. And the reason

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for that is in a subtle case in a mildly abnormal

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case. You need to know where the mesentery

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is Tethered to the abdomen. Ideally,

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it would be tethered up here at the

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ligament of trites and then in an

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oblique or diagonal fashion, you would see another tethering

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Point down here where the

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cecum should be located. If you

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have a mesentery that's got a wide broad base

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like I've demonstrated here that's a

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secure mesentery and that bowel is unlikely to rotate

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or twist or evolve your eyes, which is the emergency, of

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course that requires surgical intervention right

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away.

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If you have a narrow base of your mesentery, let's

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say the ligament of traits is here and the

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cecum is here. That is a

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very narrow base, even though the mesentery will be

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extending out broadly. It has a much

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greater likelihood to twist because it doesn't have a

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broad base. So when we see the duodenum not

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come over to the left upper quadrant. We see

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it live at the midline or maybe even on the right side and

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we identify the cecum also

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as being on the right side, we're concerned this patient is at risk to

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volvulize which is obviously the surgical emergency

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we want to avoid. So I'm just gonna finish going through

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the images of this exam. We're gonna continue to follow

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that contrast to hear. This is our final image all of

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our opacified Loops of Balor on the right we can

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see some howstra gas filled colon over

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here. Meaning our colons on the left. This is Mal rotation.

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It's not valid yet but high risk

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to do so and this needs surgical consult.

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That's the end of the case.