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How Accurate Is Upper GI Series for Diagnosing Malrotation in Children?

April 17, 2008
Written by: , Filed in: Pediatric Radiology
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The objective of a recent study was to better UGI series performance and difficulties of accurate diagnosis of children with clinically suspected malrotation.

The study has concluded that upper gastrointestinal (UGI) series studies are generally very good at diagnosing malrotation in children; however, for a troubling percentage of patients, malrotation anatomy may overlap with normal variant anatomy.

Methodology
Over a nine-year retrospective period, children who underwent an UGI series prior to undergoing a Ladd procedure were identified. Exclusion criteria included age >21 years and co-existing morbidities such as omphalocele, gastroschisis, and/or congenital diaphragmatic hernia.

The UGI examination reports were reviewed for the presence of individual signs that suggested malrotation or volvulus. These included low position of the duodenal-jejunal junction (DJJ), DJJ not located to the left of the left vertebral body pedicle, duodenal redundancy, duodenal distention, DJJ corkscrew appearance and, when available, abnormal position of the cecum.

The authors also retrospectively reviewed the medical records for data including clinical and surgical history, age, sex, presenting symptoms, prior abdominal surgery, and/or presence of congenital anomalies.

Pediatric Diagnostic Imaging

The Society for Pediatric Radiology
Pediatric Diagnostic Imaging program features the advances and diversity of pediatric imaging by reviewing state-of-the-art clinical material and advanced cutting-edge research presentations. This program presents a group of international experts who discuss state-of-the art diagnostic imaging and the outlook for the future direction of the specialty.
Read more or order:  Pediatric Diagnostic Imaging

Results of the Study
166 patients were included in the study. Of these, 40% were neonates, noted to be at peak age for malrotation and volvulus; 74% were aged <1 year. The median age was 67 days, and the overall mean age was 2.4 years. The most frequent presenting symptom was emesis of any type (59%), and bilious emesis was present in 31%. Feeding intolerance and abdominal pain were the next most common symptoms. Using surgical confirmation as the standard, the sensitivity of the UGI series was 96% for detecting malrotation and 79% for detecting volvulus. Seven patients had a false-negative UGI study, two had duodenal redundancy, and three were reported to have normal lateral views, although review indicated some obliquity of these views. An additional four patients had no lateral views on the UGI study. Both patients with false-positive results had redundant duodenum, and one patient had stomach distention creating a low DJJ, a finding attributed to lax peritoneal ligaments in children aged <4 years. Conclusions
A normal UGI series has been confirmed to be an acceptable study for diagnosing malrotation, and less so for diagnosing volvulus. A normal UGI series should always include a true lateral view to document the retroperitoneal position of the third and fourth portions of the duodenum. A meticulous technique is essential to successful interpretation of an UGI study.

Reviewer’s Comments
Not a new conclusion, but an affirmation of a concept that often gets ignored: the importance of a complete examination. Of note, the examples of the false-negative and false-positive results of this large sample size had studies that were suboptimal. The importance of meticulous technique cannot be overemphasized.

Author: Basil Hubbi, MD

Reference
Sizemore AW, Rabbani KZ, et al: Pediatr Radiol; 2008; 38 (April): 518-528:
Diagnostic Performance of the Upper Gastrointestinal Series in the Evaluation of Children With Clinically Suspected Malrotation.

Pediatric Diagnostic Imaging

The Society for Pediatric Radiology
Pediatric Diagnostic Imaging program features the advances and diversity of pediatric imaging by reviewing state-of-the-art clinical material and advanced cutting-edge research presentations. This program presents a group of international experts who discuss state-of-the art diagnostic imaging and the outlook for the future direction of the specialty.
Read more or order:  Pediatric Diagnostic Imaging
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