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DOI: 10.1148/rg.265055167
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Intestinal Malrotation in Children: A Problem-solving Approach to the Upper Gastrointestinal Series1

Kimberly E. Applegate, MD, MS, James M. Anderson, MD and Eugene C. Klatte, MD

1 From the Department of Radiology, Riley Hospital for Children, 702 Barnhill Dr, Room 1053B, Indianapolis, IN 46202. Presented as an education exhibit at the 2003 RSNA Annual Meeting. Received August 30, 2005; revision requested November 10 and received December 21; accepted April 4, 2006. All authors have no financial relationships to disclose.

Figure 1
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  		Figure 1.  Nonrotation of the bowel. Radiograph shows the presence of iodinated contrast material from an abdominal computed tomographic (CT) examination 1 day earlier. The colon is located primarily in the left side of the abdomen, and the small bowel is in the right side.

 

Figure 2
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  		Figure 2.  Radiograph obtained with barium in the upper GI tract of an infant with previously repaired gastroschisis and obligatory malrotation shows a markedly abnormal course of the duodenum and jejunum in the right abdomen.

 

Figure 3
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  		Figure 3a.  Malrotation in two infants with heterotaxy syndrome. (a) Radiograph from an upper GI series obtained with barium administered via a nasogastric tube shows a right-sided stomach, left-sided small bowel, and abnormal position of the duodenojejunal junction (arrow). (b) Radiograph in another infant shows a right-sided heart, left-sided barium-filled stomach, and right-sided barium-filled small bowel. The duodenojejunal junction (not shown) also was abnormally positioned.

 

Figure 3
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  		Figure 3b.  Malrotation in two infants with heterotaxy syndrome. (a) Radiograph from an upper GI series obtained with barium administered via a nasogastric tube shows a right-sided stomach, left-sided small bowel, and abnormal position of the duodenojejunal junction (arrow). (b) Radiograph in another infant shows a right-sided heart, left-sided barium-filled stomach, and right-sided barium-filled small bowel. The duodenojejunal junction (not shown) also was abnormally positioned.

 

Figure 4
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  		Figure 4a.  Normal upper GI series in an infant with vomiting. (a) Frontal view shows the duodenojejunal junction (arrow) to the left of a vertebral body pedicle and at the level of the pylorus. The duodenal bulb is not visible. (b) Lateral view shows a normal posterior position of the duodenum and location of the duodenojejunal junction (arrow) at the inferior aspect of the duodenal bulb (arrow).

 

Figure 4
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  		Figure 4b.  Normal upper GI series in an infant with vomiting. (a) Frontal view shows the duodenojejunal junction (arrow) to the left of a vertebral body pedicle and at the level of the pylorus. The duodenal bulb is not visible. (b) Lateral view shows a normal posterior position of the duodenum and location of the duodenojejunal junction (arrow) at the inferior aspect of the duodenal bulb (arrow).

 

Figure 5
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  		Figure 5a.  Normal variants that mimic malrotation in two infants born prematurely. (a) Frontal view shows the position of the duodenal bulb (arrow), which is superimposed over the gastric antrum, and inferior displacement of the duodenojejunal junction (arrowhead). (b) Frontal view shows a similar inferior position of the duodenojejunal junction (arrow); * = duodenal bulb. Both the clinical manifestations and the findings on other images in these upper GI series were inconsistent with malrotation and, instead, indicative of normal variations.

 

Figure 5
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  		Figure 5b.  Normal variants that mimic malrotation in two infants born prematurely. (a) Frontal view shows the position of the duodenal bulb (arrow), which is superimposed over the gastric antrum, and inferior displacement of the duodenojejunal junction (arrowhead). (b) Frontal view shows a similar inferior position of the duodenojejunal junction (arrow); * = duodenal bulb. Both the clinical manifestations and the findings on other images in these upper GI series were inconsistent with malrotation and, instead, indicative of normal variations.

 

Figure 6
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  		Figure 6a.  Malrotation with obstructing duodenal bands. Radiographs show marked distention and obstruction of the proximal part of the duodenum (a) and an abnormal location of the duodenojejunal junction and the proximal part of the jejunum in the right upper abdominal quadrant (b).

 

Figure 6
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  		Figure 6b.  Malrotation with obstructing duodenal bands. Radiographs show marked distention and obstruction of the proximal part of the duodenum (a) and an abnormal location of the duodenojejunal junction and the proximal part of the jejunum in the right upper abdominal quadrant (b).

 

Figure 7
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  		Figure 7.  Malrotation with obstructing duodenal bands in a neonate. Radiograph shows distention of the proximal part of the duodenum by barium, but no air or barium in the distal part. In this situation, it may be impossible to distinguish duodenal atresia from malrotation and volvulus. The imaging findings therefore should be discussed with the referring physician and correlated with the clinical manifestations.

 

Figure 8
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  		Figure 8a.  Malrotation with volvulus in a neonate. Radiographs obtained with barium administered via a nasogastric tube show a corkscrew appearance of the duodenum and an abnormal position of the duodenojejunal junction on both frontal (a) and lateral (b) views, features indicative of volvulus, which constitutes a surgical emergency.

 

Figure 8
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  		Figure 8b.  Malrotation with volvulus in a neonate. Radiographs obtained with barium administered via a nasogastric tube show a corkscrew appearance of the duodenum and an abnormal position of the duodenojejunal junction on both frontal (a) and lateral (b) views, features indicative of volvulus, which constitutes a surgical emergency.

 

Figure 9
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  		Figure 9a.  Malrotation with volvulus in a neonate. Radiographs obtained with barium administered via a nasogastric tube show a corkscrew appearance of the duodenum and an abnormal position of the duodenojejunal junction on both frontal (a) and lateral (b) views, features diagnostic of volvulus, which constitutes a surgical emergency. The proximal part of the duodenum also is dilated because of obstruction by the volvulus.

 

Figure 9
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  		Figure 9b.  Malrotation with volvulus in a neonate. Radiographs obtained with barium administered via a nasogastric tube show a corkscrew appearance of the duodenum and an abnormal position of the duodenojejunal junction on both frontal (a) and lateral (b) views, features diagnostic of volvulus, which constitutes a surgical emergency. The proximal part of the duodenum also is dilated because of obstruction by the volvulus.

 

Figure 10
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  		Figure 10a.  Malrotation without volvulus in an infant with nonbilious vomiting. (a) Frontal view shows the location of the entire duodenum to the right of the spine, a finding diagnostic of malrotation. (b) Lateral view shows an abnormal course of the duodenum, which is not downward and then back up to the level of the bulb, the normal location of the duodenojejunal junction.

 

Figure 10
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  		Figure 10b.  Malrotation without volvulus in an infant with nonbilious vomiting. (a) Frontal view shows the location of the entire duodenum to the right of the spine, a finding diagnostic of malrotation. (b) Lateral view shows an abnormal course of the duodenum, which is not downward and then back up to the level of the bulb, the normal location of the duodenojejunal junction.

 

Figure 11
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  		Figure 11a.  Malrotation without volvulus in an infant with vomiting and failure to thrive. (a) Frontal radiograph shows the duodenojejunal junction (arrow), which does not cross to the left of the left pedicle of the vertebral body and which is located inferior to the duodenal bulb (*). The location of the proximal jejunal loop on the right is suggestive but not diagnostic of malrotation. (b) Delayed radiograph shows the location of the jejunal loops in the right side of the abdomen. Note that the duodenum does not cross the midline.

 

Figure 11
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  		Figure 11b.  Malrotation without volvulus in an infant with vomiting and failure to thrive. (a) Frontal radiograph shows the duodenojejunal junction (arrow), which does not cross to the left of the left pedicle of the vertebral body and which is located inferior to the duodenal bulb (*). The location of the proximal jejunal loop on the right is suggestive but not diagnostic of malrotation. (b) Delayed radiograph shows the location of the jejunal loops in the right side of the abdomen. Note that the duodenum does not cross the midline.

 

Figure 12
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  		Figure 12.  Malrotation without volvulus in a neonate. Frontal view from an upper GI series shows an abnormal location of the duodenojejunal junction (arrow) at the vertebral body pedicle and inferior to the duodenal bulb. The absence of distention in adjacent bowel loops and stomach, a condition that might have caused displacement of the duodenojejunal junction, indicates that this is not a normal anatomic variant.

 

Figure 13
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  		Figure 13a.  Subtle malrotation with an abnormal position of the duodenojejunal junction in a teenaged boy. Frontal views (a, c) show redundancy of the descending part of the duodenum, before it crosses the spine, with two small-bowel loops on the right. On the lateral view (b), the duodenojejunal junction (arrow) appears in an abnormal location, inferior to the duodenal bulb. The frontal view in c helps confirm the abnormal location of the duodenojejunal junction (arrow), which is superimposed over the vertebral body, inferior to the duodenal bulb. These findings were confirmed at surgery.

 

Figure 13
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  		Figure 13b.  Subtle malrotation with an abnormal position of the duodenojejunal junction in a teenaged boy. Frontal views (a, c) show redundancy of the descending part of the duodenum, before it crosses the spine, with two small-bowel loops on the right. On the lateral view (b), the duodenojejunal junction (arrow) appears in an abnormal location, inferior to the duodenal bulb. The frontal view in c helps confirm the abnormal location of the duodenojejunal junction (arrow), which is superimposed over the vertebral body, inferior to the duodenal bulb. These findings were confirmed at surgery.

 

Figure 13
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  		Figure 13c.  Subtle malrotation with an abnormal position of the duodenojejunal junction in a teenaged boy. Frontal views (a, c) show redundancy of the descending part of the duodenum, before it crosses the spine, with two small-bowel loops on the right. On the lateral view (b), the duodenojejunal junction (arrow) appears in an abnormal location, inferior to the duodenal bulb. The frontal view in c helps confirm the abnormal location of the duodenojejunal junction (arrow), which is superimposed over the vertebral body, inferior to the duodenal bulb. These findings were confirmed at surgery.

 

Figure 14
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  		Figure 14a.  Wandering duodenum that mimics malrotation in an infant with vomiting. Frontal view (a) from an upper GI examination shows a longer and more meandering course of the duodenum instead of the typical C-shaped course, but both the frontal view and the oblique lateral view (b) show a normal position of the duodenojejunal junction (arrow).

 

Figure 14
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  		Figure 14b.  Wandering duodenum that mimics malrotation in an infant with vomiting. Frontal view (a) from an upper GI examination shows a longer and more meandering course of the duodenum instead of the typical C-shaped course, but both the frontal view and the oblique lateral view (b) show a normal position of the duodenojejunal junction (arrow).

 

Figure 15
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  		Figure 15a.  Malrotation in a 16-year-old girl with intermittent abdominal pain. (a) Transverse sonogram shows the reversal of the normal anatomic relation of the superior mesenteric artery (SMA) and superior mesenteric vein (SMV), a finding that prompted the radiologist to request an upper GI series. AO = aorta. (b) Fluoroscopic image shows an abnormal course of the duodenum into the right side of the abdomen. The colon, which is located in the left side of the abdomen, contains contrast material from an earlier CT examination. The patient underwent a Ladd procedure, which was successful.

 

Figure 15
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  		Figure 15b.  Malrotation in a 16-year-old girl with intermittent abdominal pain. (a) Transverse sonogram shows the reversal of the normal anatomic relation of the superior mesenteric artery (SMA) and superior mesenteric vein (SMV), a finding that prompted the radiologist to request an upper GI series. AO = aorta. (b) Fluoroscopic image shows an abnormal course of the duodenum into the right side of the abdomen. The colon, which is located in the left side of the abdomen, contains contrast material from an earlier CT examination. The patient underwent a Ladd procedure, which was successful.

 

Figure 16
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  		Figure 16a.  Subtle malrotation in an infant. (a) Frontal view from an upper GI series shows an abnormal location of the duodenojejunal junction (arrow), which is superimposed over the left pedicle of the vertebral body at the level of the duodenal bulb (arrowhead). (b) Lateral view shows an abnormal course of the duodenum and an abnormal position of the duodenojejunal junction (arrow), inferior to the duodenal bulb (arrowhead).

 

Figure 16
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  		Figure 16b.  Subtle malrotation in an infant. (a) Frontal view from an upper GI series shows an abnormal location of the duodenojejunal junction (arrow), which is superimposed over the left pedicle of the vertebral body at the level of the duodenal bulb (arrowhead). (b) Lateral view shows an abnormal course of the duodenum and an abnormal position of the duodenojejunal junction (arrow), inferior to the duodenal bulb (arrowhead).

 

Figure 17
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  		Figure 17.  Subtle malrotation in an infant. Frontal view from an upper GI series demonstrates an abnormal position of the duodenojejunal junction (arrow), which does not pass to the left of the left pedicle of the vertebral body (arrowhead). The proximal jejunal loop courses to the right, a location that is suggestive but not diagnostic of malrotation. The diagnosis in this case might easily be missed, especially if the duodenojejunal junction abnormality is attributed to patient positioning.

 

Figure 18
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  		Figure 18a.  Subtle malrotation in a 5-month-old infant with Down syndrome, an uncorrected atrioventricular canal defect, and a clinical history of nonbilious vomiting. Because of the latter, an upper GI series (with barium administered via a nasogastric tube) was requested by the pediatrician prior to the surgical insertion of a gastric feeding tube. (a) Frontal view from the upper GI series demonstrates a mildly abnormal location of the duodenojejunal junction (arrow), inferior to the bulb (arrowhead) and overlying the midline rather than crossing over to the left of the pedicle. The right-sided location of the proximal jejunal loops also is visible. Because of these subtle abnormalities, the barium was followed through the small bowel to the colon. (b) Delayed radiograph shows an abnormal position of the cecum (arrow indicates the cecal apex and appendix). These anatomic abnormalities imply a foreshortening of the small-bowel mesentery. Malrotation was documented at surgery.

 

Figure 18
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  		Figure 18b.  Subtle malrotation in a 5-month-old infant with Down syndrome, an uncorrected atrioventricular canal defect, and a clinical history of nonbilious vomiting. Because of the latter, an upper GI series (with barium administered via a nasogastric tube) was requested by the pediatrician prior to the surgical insertion of a gastric feeding tube. (a) Frontal view from the upper GI series demonstrates a mildly abnormal location of the duodenojejunal junction (arrow), inferior to the bulb (arrowhead) and overlying the midline rather than crossing over to the left of the pedicle. The right-sided location of the proximal jejunal loops also is visible. Because of these subtle abnormalities, the barium was followed through the small bowel to the colon. (b) Delayed radiograph shows an abnormal position of the cecum (arrow indicates the cecal apex and appendix). These anatomic abnormalities imply a foreshortening of the small-bowel mesentery. Malrotation was documented at surgery.

 

Figure 19
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  		Figure 19.  Malrotation in a 5-year-old girl. Delayed radiograph, obtained after an upper GI series, shows a markedly abnormal location of the cecum and appendix (arrow) in the epigastric region, a finding that implies a very short small-bowel mesentery and a high risk for volvulus. Barium outlines the entire colon, which is located in the left side of the abdomen. Note the gastrojejunal feeding tube, which follows the course of the duodenum and proximal jejunum. The distance between the cecum and the duodenojejunal junction (arrowhead) is very short.

 

Figure 20
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  		Figure 20.  Malrotation in a 10-year-old boy. Delayed radiograph from an upper GI series shows the cecal apex at the level of the L3-L4 intervertebral space. The abnormal location of the cecum suggests a predisposition to volvulus due to foreshortening of the small-bowel mesentery.

 

Figure 21
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  		Figure 21.  Malrotation of the colon in a female infant with Cornelia de Lange syndrome and a history of feeding difficulties with gastrojejunal tube feeds. Radiograph obtained with a barium enema shows an unusual position of the colon, which is located entirely on the right side of the abdomen, and a normal position of the small bowel. Surgery was not performed.

 

Figure 22
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  		Figure 22.  Acute volvulus of the transverse colon in a 3-week-old girl with trisomy 13, feeding intolerance (vomiting and abdominal distention), and decreased frequency of defecation. Radiograph obtained with a barium enema shows a beaklike disruption of the mid transverse colon (arrow), a sign of volvulus. At surgery for reduction of the volvulus, the colon was located mostly on the left side, and the small-bowel position was normal.

 




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