Indian Journal of Radiology and Imaging Indian Journal of Radiology and Imaging

QUIZ
Year
: 2000  |  Volume : 10  |  Issue : 3  |  Page : 181--182

Radiological quiz : Pediatric


K Uma 
 Dept of Radiodiagnosis, JJM Medical College, Davangere, India

Correspondence Address:
K Uma
Vidyanagar, Davangere-577 005
India




How to cite this article:
Uma K. Radiological quiz : Pediatric.Indian J Radiol Imaging 2000;10:181-182


How to cite this URL:
Uma K. Radiological quiz : Pediatric. Indian J Radiol Imaging [serial online] 2000 [cited 2020 Oct 29 ];10:181-182
Available from: https://www.ijri.org/text.asp?2000/10/3/181/30592


Full Text

A 15-days-old child presented with bilious vomiting since birth. On examination the child was found to be jaundiced. There was no abdominal distension or tenderness.

A plain radiograph of the abdomen, barium meal follow through [Figure 1],[Figure 2] and barium enema studies [Figure 3] were performed.

 View Answer

 Radiological Diagnosis



Type IIIA Malrotation with Ladd's Band and Obstruction of the Duodenum

The plain film of the abdomen revealed mild gastric distension with distal bowel gas. There was no evidence of abnormal dilatation of the duodenal cap.

Supine AP view [Figure 1] of the barium meal follow through study shows the misplaced duodeno-jejunal flexure, which is to the right of the L2 pedicle. A rounded radiolucency is seen posterior to the C-loop which is continuous with the large bowel gas. Subsequent left anterior oblique view [Figure 2] shows distension of the stomach and duodenum. There is incomplete obstruction of the duodenum more towards the third and fourth parts, with evidence of tapered deformity at the level of the obstruction suggestive of an extrinsic compression (closed arrow). The jejunal loops are seen descending to the right of midline. There is no "cork screw" or "twisted ribbon" appearance suggestive of volvulus.

Post-evacuation film of a barium enema [Figure 3] shows the cecum and ileocecal junction in the right hypochondrium close to the midline (closed arrow). The ascending colon is in the umbilical region and the remainder of the colon is on the left side.

Our findings were confirmed post operatively. On laparotomy, the small bowel loops were collapsed but viable. There was no volvulus. The cecum was in the right hypochondrium. The Ladd's band was cut and released and the duodeno-colic isthmus was widened.

The different diagnosis of duodenal obstruction includes malrotation with Ladd's band or volvulus or both; duodenal atresia, stenosis or web; annular pancreas and pre-duodenal portal vein. The most important of these is malrotation.

In malrotation, the obstruction by volvulus has to be urgently ruled out since it is associated with high mortality. Obstruction occurs less commonly secondary to duodenal bands or an internal hernia. Duodenal bands arise from the posterior abdominal peritoneum and extend from the liver to the colon, passing anterior to the duodenum. Usually the distal descending or the third and fourth parts of the duodenum are obstructed. These bands are usually referred to as Ladd's bands [1].

Jaundice has also been noted in some of these patients but its precise etiology is not known [2].

Midgut malrotation can be classified into three types according to the three stages of normal rotation - Types I, II and III.

Type I malrotation or nonrotation is an error in rotation before 6 weeks of gestational age. The duodenum and the large bowel stop rotating after their first 90 degrees counter-clockwise rotation, so the proximal small bowel including the duodeno-jejunal junction lie on the right and the cecum lies on the left. These are not clinically significant because good fixation prevents volvulus. Type II malrotation or duodenal malrotation occurs with an error in rotation between six and ten weeks of gestational age. The abnormality affects primarily the duodenum because this is the only portion of the bowel rotating at this time. [3],[6] Most commonly the appearance mimics duodenal atresia. This type is excessively rare [3],[4]. An error in rotation after ten weeks of gestational age results in a Type III malrotation. The duodenum has only 90 degrees of rotation left to complete and the large bowel 180 degrees.

In Type III A, on barium study, there is either a complete obstruction from Ladd's bands or volvulus. The duodeno-jejunal junction and cecum are malpositioned often lying in the midline [3]. This is the most dangerous type of malrotation. Volvulus, gangrene and death are common [3],[5]. Type III B is incomplete fixation of the hepatic flexure, type III C is incomplete fixation of the cecum and mesocecum and Type III D is an internal hernia at the ligament of Trietz.

References

1Ladd W.E.: Congenital obstruction of the small intestine. J.A.M.A. 1933; 101: 1453 - 1458.
2Porto S.O.: Jaundice in congenital malrotation of the intestine. Am. J. Dis. Child 1969; 117: 684-688.
3Smyder W.H, Chaffin L: Embryology of the intestinal tract: Presentation of 10 cases of malrotation. Am. J. Surg. 1954; 140: 368.
4Stringer DA. Paediatric gastrointerstinal imaging. BC Decker. Philadelphia: 1989
5Berdon WE, Baker DH, Bulls et al : Midgut Malrotation and volvulus: which films are most useful? Radiology 1970; 96: 375.
6Smith EI. Malrotation of intestine. Welch KJ, randolph JG, Ravitch MM et al , eds: Paediatric Surgery; 4th edition. Chicago: Mosby - year book, 1986.