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Abdomen » Gastrointestinal
Duodenal malrotation and volvulus
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Author(s) :
Taco Geertsma, MD
 
Presentation A 1 week old female presents with severe vomiting after meals and signs of beginning dehydration.
 
 
 
Caption: Transverse color doppler image of the upper abdomen
Description: Color Doppler image of the mesenteric vessels showing a spiral aspect or "whirlpool sign".
 
 
 
Caption: Upper abdomen, gastric antrum and duodenal bulb
Description: Ultrasound image of the distal gastic antrum and duodenal bulb. No pyloric hypertrophy is demonstrated.
 
 
 
Caption: Transverse upper abdomen
Description: This image suggests a “mass” with tortuous vessels
 
 
 
Caption: Longitudinal image of the same area as image #3
Description: This image presents a "swirling" or "whirlpool" appearance of the vessels associated with the "mass".
 
 
 
Caption: Radiograph 1
Description: Contrast examination of the stomach and duodenum showing a normal stomach and passage to the duodenal bulb, but with a diatated duodenal loop
 
 
 
Caption: Radiograph 2
Description: A.P view of the contrast examination after a few minutes, showing a malrotation and no passage of contrast to the jejunum
 
Differential Diagnosis gastroesophageal reflux
hypertrophic pyloric stenosis
malrotation
 
Final Diagnosis duodenal malrotation and volvulus
 
Discussion

Common  causes of vomiting in a few weeks old infant are

  • Gastroesophageal reflux
  • Hypertrophic pyloric stenosis
  • Malrotation

Ultrasound is very useful in diagnosing a hypertrophic pyloric stenosis and a malrotation

In case of a hypertrophic pyloric stenosis the hypertrophic muscle is clearly visible.

In this case the ultrasound image of the distal gastic antrum and duodenal bulb does not show a hypertrophic muscle. Also the contrast examination shows a normal passage of contrast to the duodenum

The mesenteric artery and vein normally run parallel in the upper abdomen with the artery left to the vein. An abnormal position of the mesenteric vessels can be a sign of a malrotation.  Intestinal malrotation is a developmental anomaly affecting the position and peritoneal attachments of the small and large bowels during organogenesis in foetal life. It has been defined as absent or incomplete rotation and fixation of the embryonic gut around the superior mesenteric artery. A complication of a malrotation is a volvulus. A volvulus is characterized by a pseudomass of tortuous bowel loops. The mesenteric vessels also show a tortuous or spiralizing aspect. This tortuous aspect is sometimes referred as the “whirlpool sign”

The contrast examination shows an abnormal tortuous aspect of the duodenum with total distal obstruction. Suggesting malrotation and volvulus.

Final diagnosis “whirlpool sign” in a patient with a malrotation and volvulus

For more examples of malrotation and volvulus and hypertrophic pyloric stenosis visit www.ultrasoundcases.info

 
Case References
  1. Patino MO, Munden MM. Utility of the sonographic whirlpool sign in diagnosing midgut volvulus in patients with atypical clinical presentations. J Ultrasound Med. 2004 Mar;23(3):397-401.
 
Follow Up The infant was operated and the diagnosis was confirmed.
 
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