1) Malrotation of the bowel is a common cause of volvulus and obstruction in infants and children, making an accurate diagnosis vital to avoid catastrophic consequences. 2) The normal position of the duodenojejunal junction is to the left of the vertebral body at the level of the duodenal bulb on frontal views and posteriorly on lateral views. 3) A scoring system can help determine if imaging findings are consistent with normal variation, indeterminate for malrotation, or indicative of malrotation based on the number of positive findings present.

1. Golden rules for diagnosing
intestinal malrotation
Dr/Ahmed Bahnassy
Consultant Radiologist
Riyadh Military Hospital

2. Malrotation..the ticking bomb
ANOMALIES of bowel rotation and
fixation, or malrotation, are a
common predisposing cause of volvulus
and obstruction in infancy and
Childhood.
Accurate diagnosis is vital to avoid the
catastrophic consequences of midgut
volvulus

3. Embryological basis-GIT journey

4. Malrotation and volvulus

6. Be alert
First, the initial passage of barium through
the duodenum should be observed
directly with fluoroscopy to confirm the
course of the duodenum and the position
of the duodenojejunal junction.
The duodenum often is obscured as the
more distal loops of the small bowel fill
with barium,

7. Be quick
Second, the position of the duodenojejunal
junction should be documented with the
acquisition of both frontal and true lateral
projections.

8. Be cautious
Third, the stomach should not be overfilled
with contrast.
This will cause downwards displacement of
duodenojejunal flexure in lateral view
making false positive diagnosis of
malrotation.
Too much

9. Be active
• Fourth, manual palpation may be used
during the upper GI study to determine the
mobility of the duodenum

10. Be proactive
• Fifth, other imaging studies should be
reviewed.Abnormal relation SMV/SMA in
US should raise suspicion .

11. Be patient
Sixth, if the diagnosis remains in doubt or
the upper GI tract findings are equivocal
delayed abdominal radiographs should be
acquired to identify the position of the
cecum.

13. The normal position of the duodenojejunal
junction is to the left of the left-sided
pedicles of the vertebral body at the level
of the duodenal bulb on frontal views and
posterior (retroperitoneal) on lateral views.

14. Katz criteria..historical article very
valuable in difficult cases

15. Measurement and meanings
point
line

16. Relative importance of signs

17. 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 .

18. (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),

19. (e) the vertical portion of the sweep (from the bulb apex to
the inferior flexure) longer than the
horizontal portion (from the inferior flexure
to 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 upper
quadrant, and
(i) zigzag shape of the jejunum.

20. Survival guide in controversial
cases
With this system, a single positive
finding is consistent with a normal variant
(score 0 or 1), the presence of two positive
findings is indeterminate (score 2), and the
presence of three is indicative of malrotation
(score 3).

21. Patterns of malrotation in upper GI
80% of cases

22. • 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 -.

23. Ultrasound localization of D3

24. In upper GI..anterior location of
duodeum

25. Swirling sign..controversial
significance but still worthy
Swirling SMV
anticlockwise
clockwise

26. • Abnormal caecal position is not a must in
cases of malrotation and colon malrotation
can be with normal DJ.
!

27. • Answer the surgeon question ..is there a
midgut volvulus ?

28. With volvulus..notify urgently

29. Different appearances
corkscrew
block
Anterior d
Z shape

30. Malrotation without volvulus

31. • Beware of pitfalls and normal
variants.

32. Wandering duodenum
Normal location of DJ flexure

33. Duodenum inversum
The 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)

34. Duodenal distorsion due to gastric
overdistension
Small arrows indicate the course of the duodenum and proximal jejunum. The large
arrow indicates the duodenojejunal junction projecting near the midline .
After gastric decompression, the duodenojejunal junction was normal