Golden rules for diagnosing   intestinal malrotation     Dr/Ahmed Bahnassy    Consultant Radiologist    Riyadh Military Ho...
Malrotation..the ticking bombANOMALIES of bowel rotation andfixation, or malrotation, are acommon predisposing cause of vo...
Embryological basis-GIT journey
Malrotation and volvulus
Be alertFirst, the initial passage of barium throughthe duodenum should be observeddirectly with fluoroscopy to confirm th...
Be quickSecond, the position of the duodenojejunaljunction should be documented with theacquisition of both frontal and tr...
Be cautiousThird, the stomach should not be overfilledwith contrast.This will cause downwards displacement of duodenojejun...
Be active• Fourth, manual palpation may be used  during the upper GI study to determine the  mobility of the duodenum
Be proactive• Fifth, other imaging studies should be  reviewed.Abnormal relation SMV/SMA in  US should raise suspicion .
Be patient Sixth, if the diagnosis remains in doubt orthe upper GI tract findings are equivocaldelayed abdominal radiograp...
The normal position of the duodenojejunaljunction is to the left of the left-sidedpedicles of the vertebral body at the le...
Katz criteria..historical article very    valuable in difficult cases
Measurement and meanings             point      line
Relative importance of signs
9 points Scoring(a) location of the pylorus to the left of the    spine,(b) Location of the DJJ lower than the    superior...
(d) cephalocaudal distance from the level of  the apex of the duodenal bulb to the DJJ  greater than 1.3 cm (adjusted for ...
(e) the vertical portion of the sweep (from the bulb apex to    the inferior flexure) longer than thehorizontal portion (f...
Survival guide in controversial               casesWith this system, a single positivefinding is consistent with a normal ...
Patterns of malrotation in upper GI            80% of cases
• The third part of duodeum is  retroperitoneal structure.• This location excludes malrotation 100%  as it is the ultimate...
Ultrasound localization of D3
In upper GI..anterior location of          duodeum
Swirling sign..controversialsignificance but still worthy                      Swirling SMV  anticlockwise                ...
• Abnormal caecal position is not a must in  cases of malrotation and colon malrotation  can be with normal DJ.!
• Answer the surgeon question ..is there a  midgut volvulus ?
With volvulus..notify urgently
Different appearancescorkscrew            block                     Anterior d                                  Z shape
Malrotation without volvulus
• Beware of pitfalls and normal  variants.
Wandering duodenum     Normal location of DJ flexure
Duodenum inversumThe duodenum descends then ascends to the right of the spine,before crossing horizontally to the left (sm...
Duodenal distorsion due to gastric          overdistensionSmall arrows indicate the course of the duodenum and proximal je...
Golden rules for diagnosing intestinal malrotation
Golden rules for diagnosing intestinal malrotation
Golden rules for diagnosing intestinal malrotation
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Golden rules for diagnosing intestinal malrotation

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the lecture explains golden rules in diagnosis of intestinal malrotation.

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Golden rules for diagnosing intestinal malrotation

  1. 1. Golden rules for diagnosing intestinal malrotation Dr/Ahmed Bahnassy Consultant Radiologist Riyadh Military Hospital
  2. 2. Malrotation..the ticking bombANOMALIES of bowel rotation andfixation, or malrotation, are acommon predisposing cause of volvulusand obstruction in infancy andChildhood.Accurate diagnosis is vital to avoid thecatastrophic consequences of midgutvolvulus
  3. 3. Embryological basis-GIT journey
  4. 4. Malrotation and volvulus
  5. 5. Be alertFirst, the initial passage of barium throughthe duodenum should be observeddirectly with fluoroscopy to confirm thecourse of the duodenum and the positionof the duodenojejunal junction.The duodenum often is obscured as themore distal loops of the small bowel fillwith barium,
  6. 6. Be quickSecond, the position of the duodenojejunaljunction should be documented with theacquisition of both frontal and true lateralprojections.
  7. 7. Be cautiousThird, the stomach should not be overfilledwith contrast.This will cause downwards displacement of duodenojejunal flexure in lateral viewmaking false positive diagnosis ofmalrotation. Too much
  8. 8. Be active• Fourth, manual palpation may be used during the upper GI study to determine the mobility of the duodenum
  9. 9. Be proactive• Fifth, other imaging studies should be reviewed.Abnormal relation SMV/SMA in US should raise suspicion .
  10. 10. Be patient Sixth, if the diagnosis remains in doubt orthe upper GI tract findings are equivocaldelayed abdominal radiographs should beacquired to identify the position of thececum.
  11. 11. The normal position of the duodenojejunaljunction is to the left of the left-sidedpedicles of the vertebral body at the levelof the duodenal bulb on frontal views andposterior (retroperitoneal) on lateral views.
  12. 12. Katz criteria..historical article very valuable in difficult cases
  13. 13. Measurement and meanings point line
  14. 14. Relative importance of signs
  15. 15. 9 points Scoring(a) location of the pylorus to the left of the spine,(b) Location of the DJJ lower than the superior end plate of L-2,(c) DJJ to the right of the left pedicle .
  16. 16. (d) cephalocaudal distance from the level of the apex of the duodenal bulb to the DJJ greater than 1.3 cm (adjusted for patient size by dividing the actual measurement by a correction factor: the sum of the interpediculate distance at T-1 I and distance between T-11 and T-12 superior end plates divided by 2),
  17. 17. (e) the vertical portion of the sweep (from the bulb apex to the inferior flexure) longer than thehorizontal portion (from the inferior flexureto the DJJ),(f) length of the horizontal segment less than 2.6 cm (adjusted for size by using the same correction factor),(g) obstruction of the horizontal segment,(h) jejunum located in the right upperquadrant, and(i) zigzag shape of the jejunum.
  18. 18. Survival guide in controversial casesWith this system, a single positivefinding is consistent with a normal variant(score 0 or 1), the presence of two positivefindings is indeterminate (score 2), and thepresence of three is indicative of malrotation(score 3).
  19. 19. Patterns of malrotation in upper GI 80% of cases
  20. 20. • The third part of duodeum is retroperitoneal structure.• This location excludes malrotation 100% as it is the ultimate proof of completion of embryonic journey of fetal GIT .• Useful sign while doing upper GI ..in either way + or -.
  21. 21. Ultrasound localization of D3
  22. 22. In upper GI..anterior location of duodeum
  23. 23. Swirling sign..controversialsignificance but still worthy Swirling SMV anticlockwise clockwise
  24. 24. • Abnormal caecal position is not a must in cases of malrotation and colon malrotation can be with normal DJ.!
  25. 25. • Answer the surgeon question ..is there a midgut volvulus ?
  26. 26. With volvulus..notify urgently
  27. 27. Different appearancescorkscrew block Anterior d Z shape
  28. 28. Malrotation without volvulus
  29. 29. • Beware of pitfalls and normal variants.
  30. 30. Wandering duodenum Normal location of DJ flexure
  31. 31. Duodenum inversumThe duodenum descends then ascends to the right of the spine,before crossing horizontally to the left (small arrows).The duodenojejunal junction is at a normal location (large arrow)
  32. 32. Duodenal distorsion due to gastric overdistensionSmall arrows indicate the course of the duodenum and proximal jejunum. The largearrow indicates the duodenojejunal junction projecting near the midline .After gastric decompression, the duodenojejunal junction was normal

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