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Malrotation is estimated to occur in 1 in every 500 children, and while many are asymptomatic, volvulus can occur resulting in a high rate of morbidity and mortality from ischemic bowel. Most of these patients will present within the first month of life.
Bilious emesis in an infant should immediately prompt consideration of this life-threatening condition, but what is the testing modality of choice?
While Fluoroscopic Upper GI Series (UGIS) has historically been looked to as the gold standard there are many issues with this method. It requires contrast, radiation exposure and an in-house radiologist to perform the imaging, oftentimes necessitating a transfer. Due to this, many algorithms have moved to Ultrasound (US) as the first test for these patients.
UGIS has a sensitivity for malrotation of 93-100%, but only as high as 89% for volvulus while US has a sensitivity and specificity of 94% and 100% respectively for midgut volvulus.
US findings suggestive of volvulus include the classic “whirlpool sign” with twisting of the superior mesenteric vein around the superior mesenteric artery seen on Doppler, dilated proximal duodenum, or free fluid in the abdomen.
So next time there is an infant presenting with bilious emesis, consider ultrasound as your first step to save a baby's bowel!
References
McCurdie FK, Meshaka R, Leung G, Billington J, Watson TA. Ultrasound for infantile midgut malrotation: Techniques, pearls, and pitfalls. Pediatr Radiol. 2024 Dec;54(13):2099-2111. doi: 10.1007/s00247-024-06067-4. Epub 2024 Oct 15. PMID: 39404889.