Malrotation Without Midgut Volvulus

Etiology: Abnormal rotation of the gut as it returns to the abdominal cavity during embryogenesis
Imaging AXR: Usually unremarkable
Imaging US: Reversal of normal relationship of superior mesenteric vein and superior mesenteric artery on axial images – super mesenteric vein is to the right of the superior mesenteric artery in the body, if the superior mesenteric vein is above or to the left of the superior mesenteric artery in the body it should raise suspicion for malrotation being present
Imaging UpperGI: Duodenal-jejunal junction (ligament of Treitz) is where retroperitoneal duodenum comes out into peritoneum and it needs to be over left pedicle of spine or to left of spine and to be at level of duodenal bulb and failure to meet both of these criteria results in diagnosis of malrotation with small intestine in right side of abdomen and colon in left side of abdomen
Note: Distal small bowel obstruction can displace duodenal jejeunal junction making evaluation of malrotation on UpperGI difficult
Imaging Enema: Abnormal position of cecum out of right lower quadrant either high in position in the right abdomen or anywhere on the left side of the abdomen should raise suspicion for malrotation being present
Imaging CT: Follow course of duodenum – normally third part of duodenum passes retroperitoneally between aorta and superior mesenteric artery – if third part of duodenum does not do this there is malrotation
DDX:
Complications:
Treatment: Ladd’s procedure
Clinical: Commonly seen in heterotaxy syndrome

Radiology Cases of Malrotation Without Midgut Volvulus

Small bowel follow through of malrotation without midgut volvulus — Delayed AP image from an upper GI shows the ligament of Treitz to be over the right pedicle of the L2 verteral body and all of the jejunum to be on the right side of the abdomen.

CT of malrotation without midgut volvulus — Axial CT with contrast of the abdomen shows the unopacified small bowel on the right side of the abdomen and the colon on the left side of the abdomen.

UGI of malrotation without midgut volvulus — AP image from an UGI exam performed through a feeding tube whose tip is in the duodenal bulb shows the entire duodenum, the ligament of Treitz and the proximal jejunum to lie in the right side of the abdomen. There is no evidence of obstruction or midgut volvulus.

UGI of malrotation without midgut volvulus — Serial images from an UGI exam show the ligament of Treitz is to the right of the spine and at approximately the level of the duodenal bulb. There was free passage of contrast through the duodenum and no evidence of duodenal or proximal jejunal obstruction.

UGI of malrotation without midgut volvulus — AP image from an UGI exam (above) shows a redundant second portion of the duodenum to the right of the spine. AP image from later in the exam (below) shows the duodenal-jejunal junction to project over the middle of the spine and to be much lower in position than the duodenal bulb.

UGI of malrotation without midgut volvulus — AP image from an UGI exam shows the duodenal-jejunal junction is just to the right of the spine at the level of the L2 vertebral body and is low in position, being beneath the level of the duodenal bulb.

Radiology Cases of Malrotation Without Midgut Volvulus and Meconium Plug Syndrome

Enema of meconium plug syndrome — AP image from a contrast enema exam (left) shows a long filling defect in the colon within a normal caliber colon. The cecum was noted to be in the left mid abdomen. The terminal ileum was not refluxed. AP image from an upper GI exam (right) shows that while the duodenal jejunal junction projects over the left pedicle of the spine it is much lower in position than the duodenal bulb.

Radiology Cases of Malrotation Without Midgut Volvulus in Heterotaxy

Upper GI of malrotation without midgut volvulus in heterotaxy — AP image from an upper GI shows the ligament of Treitz to be in the right upper quadrant. There is no evidence of duodenal obstruction. The proximal jejunum is also in the right upper quadrant. There is also gastroesophageal reflux.

CXR of heterotaxy syndrome and upper GI of malrotation without midgut volvulus — CXR AP (above) shows the cardiac apex to be in the right hemithorax and the gastric bubble to be in the left upper quadrant. AP image from an upper GI (below) shows the ligament of Treitz to be in the right upper quadrant. There is no evidence of duodenal obstruction. The proximal jejunum is also in the right upper quadrant.

US and upper GI of malrotation without midgut volvulus in heterotaxy syndrome — Transverse color doppler US of the abdomen (below left) shows an apparent reversal of the normal positions of the superior mesenteric artery and superior mesenteric vein. This is confirmed on the spectral doppler US of the aforementioned mesenteric vessels (above). AP image from an upper GI exam (below right) shows situs inversus with levocardia and the stomach in the right upper quadrant. The duodenum is redundant and the duodenal jejunal junction is over the right pedicle of the T11 vertebral body. The cecum was in the midline.

Radiology Cases of Malrotation With Midgut Volvulus Before Ladd Procedure and Malrotation Without Midgut Volvulus After Ladd Procedure

UGI of malrotation with midgut volvulus before and after a Ladd procedure — AP (above left) and lateral (above right) images from an upper GI exam on day of life 1 show dilation of the first part of the duodenum and a spiral or corkscrew appearance of the second and third parts of the duodenum with the ligament of Trietz projecting over the midline of the spine and lower than the first part of the duodenum. AP (below left) and lateral (below right) images from an upper GI obtained several days after a Ladd procedure show the first part of the duodenum now to be normal in caliber while the second and third parts of the duodenum continue to have a spiral or corkscrew appearance with the ligament of Trietz continuing to project over the midline of the spine and lower than the first part of the duodenum.

Surgery Cases of Malrotation Without Midgut Volvulus

Surgical image of Meckel diverticulum causing closed loop bowel obstruction — Surgical image shows a closed loop small bowel obstruction caused by a small band of tissue (between the forceps) extending from small bowel to a purple in color Meckel diverticulum (center of image) arising from the antimesenteric border of the small bowel.