0:01

This was a one week old infant who presented

0:03

with ous emesis.

0:04

And so I mentioned

0:06

that at our institution our first line imaging study

0:09

of choice is ultrasound.

0:11

And to be honest, when I'm reviewing these ultrasounds,

0:14

I skip the still images

0:15

and I go straight to the cinematic images

0:17

'cause I wanna see the midgut structures,

0:20

I wanna see the relationship of everything.

0:21

And for me it's easier to do that on the, so um,

0:25

here we are, the stenographer has labeled it D three.

0:29

We are looking from superior to inferior

0:33

and we're trying to see if we can see aorta,

0:36

if we can see superior mesenteric artery.

0:39

And honestly, I'm having a hard time on this image.

0:41

Let's go to a different gray scale.

0:44

Um, okay, so here, oh, this is much better.

0:47

So we do have, unfortunately a little bit of

0:50

gas in our stomach

0:51

and we have a hard time seeing dependent to

0:53

that gas in that stomach.

0:55

But on the cinematic image, as we're going superior

0:58

to inferior, we can see vertebral body.

1:00

This is aorta.

1:02

Um, this is going to be either celiac

1:04

or superior mesenteric artery.

1:06

So let's see if we can see,

1:09

let's see if we can see beyond that.

1:10

Okay, so this is superior mesenteric vein.

1:13

Um, I think part of this is superior mesenteric artery.

1:16

Um, and they sort of have, uh, it's honestly hard

1:20

to tell the configuration of the,

1:21

of those two vessels with one another.

1:24

But as we're going from superior to inferior, we do see

1:28

a pertinent abnormal finding.

1:29

And that is the swirling of structures in the center

1:32

of the abdomen here.

1:33

So even though we have a hard time seeing the relationship

1:36

of superior, esoteric Maine

1:38

and superior mesenteric artery, we see a mid gut ulus here.

1:41

So we can tell that this is going

1:43

to be superior mesenteric artery.

1:44

It has that academic halo at the periphery.

1:47

Um, to be honest with you,

1:49

I have a hard time following the origin of it,

1:51

but it doesn't matter

1:53

'cause this is not rotation with mid gut ulu, um,

1:56

until proven otherwise, I think the person

1:59

who read this study was, um, not quite as confident as he

2:03

or she should have been because this patient went on

2:05

to upper GI to confirm this abnormality

2:07

that we saw sonographic.

2:10

So this patient went on to upper gi immediately following

2:14

that ultrasound, we have placed an enteric tube

2:17

and we have injected a little bit of contrast into

2:19

that distal esophagus.

2:21

The first thing we see is reflux of

2:23

that water soluble contrast, um, back into the, um,

2:26

distal esophagus.

2:28

So we roll the patient to try to get that contrast

2:30

to go into the stomach.

2:32

We still are having reflux, but that's okay.

2:34

We have a gas distended stomach.

2:36

So even though we have given contrast into the,

2:39

into the stomach, we have a lot of, um, gas additionally in

2:43

that, in that stomach.

2:44

So you can, you can see why it was challenging for us

2:46

to see at ultrasound.

2:48

Um, on that preceding study.

2:51

We have lots of reflux contrast going back

2:53

up into that esophagus.

2:55

So, um, so this was the supine image

2:57

where we start, then we roll

2:58

The patient right lateral decubitus.

3:00

So we see this contrast and gas descending the stomach.

3:05

Um, as we go on, we see a little bit of contrast start

3:08

to trickle through the pric channel into

3:11

the duodenal bulb here.

3:13

Um, we're starting to see the um, uh, second portion

3:17

of the duodenum here.

3:20

We have flipped the patient back supine to try to get some

3:24

of that contrast to pass beyond that duodenum.

3:27

Um, but mostly we're seeing reflux

3:30

or backwards retrograde motion

3:31

of this contrast into the dilated, um, proximal duodenum.

3:37

And then we flip the infant again, right lateral decubitus.

3:40

So this is anterior patient, this is posterior patient

3:43

where we have marked dilation of, uh, contrast in

3:47

that duodenum or dilation of the duodenum by that contrast.

3:51

And then we are trying to roll the patient to try to get

3:53

that contrast to pass through.

3:55

And here we start to see a little tiny stream

3:58

of contrast moving through.

4:00

So, um, let's pay attention to where that goes.

4:05

Okay, so here is, here's the money of

4:07

where you can see what's happening.

4:08

And this is challenging to see, I will admit we start

4:11

to see contrast trickling in

4:14

and then we see this kind of corkscrew

4:16

of a little trickling stream of contrast moving through.

4:20

So that is the midgut ulu here.

4:23

You can see it a little bit

4:24

as we're flipping the patient from, um, decubitus to supine.

4:28

You see this sort of corkscrew

4:30

or s shape configuration of contrast as it passes through.

4:34

So if you had a hard time seeing on the ultrasound,

4:36

you also have a hard time seeing on this fluoroscopy.

4:40

Um, but this upper GI does confirm our, uh,

4:43

suspected malrotation with midgut vois on our, um,

4:46

ultrasound at Upper gi.

4:48

A reminder that normally the duodenum should, um,

4:51

course inferiorly, uh,

4:53

just like on ultrasound we should have a retroperitoneal

4:56

course of duodenal the third portion of the duodenum.

4:58

So it should cross, um,

5:00

across midline into the left side of the abdomen.

5:02

And then duodenal degen junction should be up here.

5:05

This is abnormal 'cause the duodenum never goes

5:09

superiorly and across midline.

5:10

It stays on the right side

5:11

and then it corkscrews down, um, on the right side

5:15

or in the central portion of this app.

5:16

This, uh, this patient on this upper gi.

5:19

So malrotation ovulus not only at ultrasound

5:21

but at upper GI.