Pediatric emergency medicine trisk 3764 3764

FIGURE 116.10 A: Malrotation of the bowel. Supine plain roentgenogram of the abdomen
shows distended stomach and proximal duodenal loop. B: Same patient as in (A ). Upper
gastrointestinal series shows dilated proximal duodenum with abrupt transition to normal
caliber of small bowel. Abnormally placed ligament of Treitz. Proximal jejunum in the right
abdomen.

On physical examination, there may be only mild distension of the abdomen
because the obstruction usually occurs high in the GI tract. On palpation, the
physician may discern one or two prominently dilated loops of bowel. The
abdomen may be diffusely tender and yet not have signs of peritonitis early in the
course. On rectal examination, the presence of blood on the examining finger is
an alarming sign of impending ischemia and gangrene of the bowel.
Management. The key to management is to be suspicious of malrotation and to
obtain supine and upright radiographs of the abdomen immediately. The presence
of loops of small bowel overriding the liver shadow is suggestive of an
underlying malrotation. When complete volvulus has occurred, there may be only
a few dilated loops of bowel with air–fluid levels. Distal to the volvulus, there
may be little or no gas in the GI tract. A “double-bubble sign” is often present on
an upright film because of partial obstruction of the duodenum causing distension
of the stomach and first part of the duodenum ( Fig. 116.10A ).
When a child is being assessed for possible malrotation (with or without
volvulus), an upper GI series is the study of choice. The ligament of Treitz is
absent in the malrotation anomaly; therefore, the C-loop of the duodenum is not
present, the duodenum lies to the right of the spine, and the jejunum presents a
coiled spring appearance in the right upper quadrant ( Figs. 116.10B and 116.11 ).
The cecum is not fixed and usually assumes a position in the right upper
quadrant. However, because of its mobility, the cecum on barium enema may be
seen in its normal position in the right lower quadrant. Therefore, a barium enema
is not the most reliable study to rule out malrotation. In the neonate, the cecum