0:00

Okay, so let's move on to another important use

0:02

of ultrasound in the, uh,

0:04

neonatal intensive care unit setting.

0:06

And that is to help us, um, not have

0:09

to come in fluoroscopically.

0:11

Um, so mal rotation, uh, midgut mal rotation is uh,

0:15

referring to all of the bowel that is supplied

0:17

by the superior mesenteric artery.

0:20

Um, it is not an uncommon abnormality.

0:23

It's present in, um, almost four out of 10,000 live births,

0:28

um, that is complicated by midgut ulu.

0:31

Um, and most

0:32

of those patients present within the first year of life.

0:35

So midgut mal rotation with um, ulu.

0:39

The problem with malrotation

0:40

with midgut VUIs is bowel necrosis

0:43

and that can lead to short gut syndrome

0:45

because the superior mesenteric artery supplies everything

0:49

from the, um, mid third portion of the duodenum

0:52

through the mid transverse colon.

0:55

Um, the four gut is the, uh, thoracic structures

0:58

behind gut is that supplied by, um,

1:01

the inferior mesenteric artery.

1:02

And so that can unfortunately lead

1:04

to pretty high mortality rates if it is not diagnosed in

1:08

an expeditious manner.

1:10

A reminder of normal embryology

1:12

and normal development is that midgut structures herniate

1:15

through the umbilical stock in utero, it rotates 90 degrees.

1:20

And so if you have a space occupying lesion

1:22

that will prohibit that normal um, rotation

1:26

or you have oligo hydros, um, causing not enough space

1:29

that can increase rates of malrotation.

1:32

Um, then in utero the bowel, uh, reentries

1:35

through the umbilicus and twists another 270 degrees.

1:39

And so you have this broad mesenteric stock

1:41

that prohibits the gut from twisting on itself.

1:45

If you have malrotation,

1:46

that means you have a narrow pedicle from

1:48

abnormal gut fixation.

1:50

And so that is why those patients are

1:52

predisposed to the gut.

1:53

Vois a reminder that usually my rotation

1:56

with mid gut vois presents with ous emesis, which is green,

2:00

green emesis in a newborn baby,

2:03

but up to 25% of them might not initially have ous emesis.

2:08

Um, initially, eventually they all, they all turn ous

2:11

because again, the level

2:13

of twisting is the right at the mid portion

2:15

of the third portion of the duodenum, which is

2:18

beyond the ular of Vader.

2:20

So you have ous content that is thrown up in these infants.

2:25

Um, previously if you had an infant who presented with um,

2:29

ous emesis, that patient would go

2:31

immediately straight to upper gi.

2:33

So we could look for normal rotation

2:36

or abnormal rotation with concomitant ous.

2:38

And this is just an example of an abnormal upper GI

2:41

where you have this corkscrew of the ulus.

2:44

Um, on this lateral view, um, all

2:46

of our small bowel is normally located in this left upper

2:49

abdomen on this delayed image

2:51

of this patient on this upper gi,

2:53

but with radiologist shortages

2:55

and increased uh, skills with ultrasound,

2:58

we can diagnose malrotation, midgut ulu with ultrasound.

3:01

So our new workflow is if we have a patient

3:04

with clinical concern for malrotation

3:06

and midgut ulus, they go straight to ultrasound.

3:09

We have techs in-house 24 7 even on holidays.

3:13

And so, um, rather than a radiologist having

3:16

to get called in in the middle of the night, for example,

3:18

to do an upper gi, these patients will go

3:20

to ultrasound to triage them.

3:22

If the tech finds midgut ulus in the middle of the night,

3:25

those patients go straight to the OR

3:27

to undergo a labs procedure.

3:29

So they, um, untwist the bowel and then they tack it down.

3:32

If we can't see

3:34

or we have a normal um, ultrasound with no ulus,

3:37

if they still have a high enough pretest probability

3:40

of mal rotation with mid up ulus, they'll let us wait

3:43

until the morning to do an upper gi.

3:45

And then depending on what we see,

3:46

they'll either go like just clinical management for reflux

3:49

for example, or if um, they still are thinking that it's um,

3:54

malrotation may go ulu, then they'll go to the OR

3:56

after an epi GI in the next morning.

3:58

We do at our institution use ultrasound

4:00

for triaging in the setting of like an x-ray

4:04

with a classic distal obstruction bowel gas pattern.

4:06

Um, I'll show you some examples of that

4:08

because sometimes those patients present with

4:10

ous emesis also and they want to rule out concomitant ous.

4:15

And so we will do that with ultrasound.

4:18

So we need to know what normal anatomy is to be able

4:21

to talk about abnormal rotation.

4:23

And then, um, concomitant ous.

4:25

So a normal midgut rotation,

4:27

normal midgut anatomy is a retroperitoneal third

4:30

portion of the duodenum.

4:32

So you will see duodenum crossing

4:33

between superior mesenteric artery and the aorta.

4:36

That is normal anatomy.

4:38

The other thing is that the superior mesenteric vein will be

4:41

on portal vein side of the patient.

4:43

I used to say right side and left side,

4:45

but that gets confusing when you're checking about right

4:47

side of the image versus right side of the patient.

4:48

So SMV is on portal vein side of the patient.

4:52

Superior mesenteric artery is on

4:53

the opposite side of the patient.

4:55

The finding that to me is the least helpful in confirming

4:59

normal rotation is that the cecum

5:00

and ideally the appendix are located in the

5:03

right lower abdominal quadrant.

5:04

Um, midgut structures are the duodenum D three

5:08

crossing retroperitoneum.

5:09

That's how you can be confident that you have a patient

5:11

with normal midgut anatomy.

5:14

So this is what that looks like on ultrasound.

5:17

So superior mesenteric artery is

5:18

on spleen side of the patient.

5:20

Super mesenteric vein is on portal vein side of the patient

5:22

and we'll see duodenum third portion crossing

5:26

between the abdominal aorta

5:27

and the superior mesenteric artery.

5:29

Um, another landmark that can help you know

5:32

that you're at the correct location is

5:33

that you'll see the left renal vein crossing over.

5:36

So, um, this is the money for when you wanna, uh,

5:40

decide if somebody has normal mid gut anatomy versus

5:44

abnormal midge anatomy.

5:46

So our protocol is going to be that we're gonna look

5:48

for our mid gut structures on a cinematic transverse gray

5:51

scale where we go superior to inferior from the level

5:55

of the pylorus all the way through the urinary bladder.

5:58

'cause we're looking for any sort of twisting of structures,

6:01

um, that would suggest a ulus.

6:04

So more examples of normal anatomy, um,

6:06

and normal, uh, ultrasound scanning technique.

6:09

Again, we go from the level of the pori.

6:11

Ideally we wanna connect that pylorus all the way

6:15

through duodenal bulb through first

6:16

and second portions of the duodenum

6:18

through third portions of the duodenum.

6:20

Um, sometimes that is not possible

6:22

and that's when you look at the level

6:24

of the pancreatic head at the level of the left renal vein

6:27

to see normal third portion of the duodenum crossing

6:30

between superior mesenteric artery and the aorta.

6:33

You might have to roll a patient if you

6:35

have bowel gas in the way.

6:36

And then, um, I often find that there is a lot

6:39

of bowel gas in the transverse colon of infants,

6:41

even newborn infants.

6:43

And so I find it helpful to take my transducer at the level

6:46

of the bolus and angle up, um, rather than coming superiorly

6:49

to inferiorly to be able to try to see that third portion

6:52

of the duodenum having a normal retroperitoneal location.

6:56

Some examples from the literature

6:58

of normal third portion of the duodenum.

7:00

So here's SMA, here's aorta, third portion

7:02

of the duodenum normally crossing here.

7:05

This is the level of the left kidney.

7:07

Couple more examples from the literature.

7:09

Uh, duodenum can be filled with air, it can be collapsed,

7:12

it can be full of fluid.

7:14

So this one is full of, um, like milk content

7:17

with shadowing gas.

7:19

This is a collapsed third portion of the duodenum crossing

7:21

between the SMA and the aorta.

7:23

And this is a fluid filled third portion

7:25

of the duodenum crossing

7:26

between the superior mesenteric artery

7:27

and the aorta here with this super distended stomach

7:31

as well in this infant.

7:33

So, um, once we see that anatomy,

7:35

we can be confident we have normal midgut structures.

7:39

Um, even if we don't,

7:41

if we can't see midgut structures well, we want

7:43

to exclude midgut ulu.

7:45

So midgut ulu is a whirlpool or a twisting

7:48

or a hurricane of structures, if you will, um, twisting

7:52

around the superior mesenteric artery.

7:54

So a couple of things to note in this cinematic image.

7:57

Number one, we have a fluid-filled dilated stomach.

8:00

At this left hand side of the screen,

8:02

we have a fluid filled dilated duodenum normal rotation.

8:06

We would expect duodenum to cross

8:08

between the superior mesenteric artery in the aorta.

8:11

In this case, this fluid-filled duodenum starts

8:14

to go across midline,

8:15

but then it gets pulled anteriorly into this, um,

8:20

whirlpool of structure.

8:21

So this is ma uh, malrotation with midgut foss.

8:25

Again, this duodenum is fluid filled.

8:27

It is wrapped in a clockwise swirl

8:29

around this structure here,

8:31

which is the superior mesenteric artery.

8:34

Um, this superior mesenteric vein is completely

8:37

collapsed in this patient.

8:38

Um, so how do we know this is the

8:40

superior mesenteric artery?

8:41

It has this academic halo around it.

8:44

So the SMA is like an angel. It has a halo around it.

8:48

That's how I, my silly brain remembers it.

8:50

This is superior mesenteric artery with this genic halo

8:53

with all of these structures wrapped around

8:54

It.

8:55

A few more examples. Um, this is a still image of

8:58

that same patient showing you dilated fluid filled duodenum.

9:02

You can see a beaconing of this, uh, duodenum going anterior

9:06

to the superior mesenteric artery.

9:08

A reminder of normal, it should cross here between the aorta

9:12

and, uh, SMA, which it does not.

9:14

And then this is the whirlpool of the ulu of, um,

9:18

the mid gut structures around the SMA.

9:20

So it's not just vessels that are being pulled into this,

9:23

it's bowel and mesenteric bat

9:25

that are getting wrapped into this ous as well.

9:28

Here's another example of that.

9:30

Clockwise swirling of structures as you're going superior

9:32

to inferior of the whirlpool of malrotation

9:36

with mid gut ulus.

9:38

One more cinematic series showing

9:40

you exactly the same thing.

9:41

This whirlpool of structures

9:43

around the superior mesenteric arteries.

9:45

So mid gut ulus, here's that clockwise swirling of badness.

9:52

Um, one more example of malrotation mid ulus on ultrasound

9:56

and our tech is, was confused about what was going on.

9:58

Anytime your sonographer puts a question mark, you know

10:00

that they're like, what the heck is going on?

10:02

Or they'll say SMA area.

10:04

So although SMV is on the portal venous side of this patient

10:09

and super mesenteric arteries on the spleen side, um,

10:12

as we come inferior, we see this, um,

10:15

this is our proximal duodenum

10:17

and it's being dragged anterior into this um, whirlpool.

10:22

So this is theup ulu that clockwise swirling

10:25

of not only bowel,

10:27

but also vascular structures

10:28

around the superior mesenteric artery.

10:31

So this is what we're looking for when we are doing, um,

10:34

ultrasound, looking for malrotation with mid.