An atypical clinical presentation of acute appendicitis in a young man with midgut malrotation

Midgut malrotation occurs as a result of failure in normal intestinal rotation and fixation during early pregnancy. Pathological conditions reported in the literature involving midgut malrotation predominantly relate to infants and children. In adults malrotation is often revealed as an incidental finding on computed tomography (CT), or the associated altered anatomy can be the cause of atypical clinical symptoms of relatively common intestinal disorders.An unusual presentation of acute appendicitis, with fever and recurrent pain in left iliac fossa is reported. Underlying intestinal malrotation delayed the correct clinical diagnosis of acute appendicitis. It was not until a CT scan was performed that a malrotation was identified. The predominant appearances of malrotation are the siting of the ascending colon, caecum (and appendix) in the left side of the abdomen and the right-sided placement of the duodenojejunal junction.     

CT presentation of ruptured appendicitis in an adult with incomplete intestinal malrotation

Intestinal malrotation is defined anatomically as a developmental anomaly. It may cause atypical clinical symptoms in relatively common intestinal disorders because of the altered anatomy. A 64-year-old man presented with acute mid-abdominal pain. Underlying incomplete malrotation prevented the correct clinical diagnosis of ruptured appendicitis. Computer tomography demonstrated typical signs of malrotation, i.e., right-sided duodenojejunal junction, left position of cecum, inverted position of the superior mesenteric vessels, and pathology revealed a ruptured appendix with an abscess and a coincident mucinous cystadenoma.     

Quantification of C2 cervical spine rotatory fixation by X-ray,MRI and CT

Atlanto-axial rotatory displacement is known to be a cause of childhood torticollis and may as well be responsible for chronic neck pain after rear-end automobile collisions. The objective was to determine whether quantification of C2 malrotation is possible by plain radiographs in comparison to CT as the golden standard. MR imaging was evaluated as to whether it was of equal value in the detection of bony landmarks. C2 vertebra of five human cadaveric cervical spine specimens, ligamentously intact, were rotated using a Steinmann pin in steps of 5° up to 15° right and 15° left. Plain radiographs, CT and MRI images were taken in each rotational step. Data were analyzed for quantification of C2 rotation by three independent examiners. A rotation of 5° led to a spinous process deviation (SPD) from the midline of 3 mm as measured on an a.p. plain radiograph. A coefficient of rotation was calculated (1.62° mm^–1). Data analyzed by three examiners revealed a small coefficient of variation (0.03). MRI and CT measurements showed comparable results for the quantification of rotation; however, in both techniques the 15° rotation was underestimated. Quantification of upper cervical spine malrotation was possible on plain radiographs using the SPD and a rotation coefficient. MRI and CT were equally successful in the assessment of C2 malrotation.     

Acute appendicitis in a young adult with midgut malrotation: a case report

Midgut malrotation is defined as a developmental anomaly that may cause atypical clinical symptoms in relatively common intestinal disorders due to altered anatomy. A 27-year-old woman presented with acute left-sided abdominal pain. Underlying type Ia malrotation prevented the correct clinical diagnosis of perforated, ulcerated appendicitis. Cross-sectional imaging demonstrated all the typical signs of this type of malrotation, i.e., right-sided duodenojejunal junction, left positioned cecum and ascending colon, inverted position of the superior mesenteric vessels, and hypoplasia of the uncinate process of pancreas, and surgical treatment was initiated.     

Superior mesenteric vascular anatomy at US in patients with surgically proved malrotation of the midgut.

The purpose of this study was to determine the frequency with which inversion of the superior mesenteric artery (SMA) and superior mesenteric vein (SMV) is seen at ultrasound (US) in children with malrotation. Nine patients with malrotation at upper gastrointestinal (UGI) radiographic examination (surgically confirmed) were studied prospectively. Anatomic relationships between the SMA and SMV were evaluated with real-time US in an axial projection, with the transducer placed at the midline of the anterior abdomen. Use of duplex imaging confirmed which vessel was the artery and which was the vein. Vessels were considered to be inverted if the SMV was left of the left lateral margin of the SMA. The SMA and SMV were inverted in six patients (67%) and were normal in three (33%). One patient with normal mesenteric vessels had midgut volvulus; duodenojejunal resection was required. Inversion of the SMA and SMV at US is not sufficiently sensitive to screen patients for malrotation. UGI examination remains the standard modality to diagnose this disorder.     

Sonographic diagnosis of intestinal malrotation in infants: importance of the relative positions of the superior mesenteric vein and artery.

OBJECTIVE. An abnormal relative position of the superior mesenteric vein and artery can be present in patients with intestinal malrotation. We undertook this retrospective study to see how often we could determine the relative position of these vessels on abdominal sonograms in infants and how often abnormal position of the vessels was associated with malrotation. MATERIALS AND METHODS. We reviewed the radiology files and medical records of 337 infants with vomiting who were referred for sonography because of possible pyloric stenosis. We used sonograms and written reports to determine the position of the superior mesenteric vessels. The position was considered normal when the superior mesenteric vein was to the right of the superior mesenteric artery on transverse sonograms. The position was considered abnormal when the vein was directly ventral to the artery or when the vein was to the left of the artery. Sonographic findings were compared with results of upper gastrointestinal series when possible and with clinical outcome. RESULTS. The relative positions of the superior mesenteric vein and artery were evident in 249 (74%) of the 337 patients. Abnormal orientation of the mesenteric vessels was detected in nine patients. In five patients, the superior mesenteric vein was located to the left of the artery, and all five had intestinal malrotation. In four patients, the superior mesenteric vein was directly ventral to the artery, and one of these had malrotation. CONCLUSION. Sonographic assessment of the relative positions of the mesenteric artery and vein is an important adjunct in the examination of infants with suspected pyloric stenosis. Patients in whom sonograms show an abnormal position of the vessels should have further examination to detect malrotation.     

Cryptic cause of renal malrotation

An intravenous urogram in a child with left adrenal neuroblastoma and bone metastases deomonstrated malrotation of the left kidney but no visible mass. A bone scan showed uptake of 99mTc by the tumor which suggested the diagnosis, confirmed by an abdominal echogram.     

儿童中肠旋转不良及扭转的分析

文章报道了30例年长儿童的中肠旋转不良及扭转，讨论了中肠旋转不良的病理解剖和发病机制。作者认为X线检查，尤其是钡剂灌肠对正确诊断非常重要，X线征象包括（1）立位平片显示“双泡”征；（2）胃肠钡餐出现十二指肠梗阻，（3）钡剂灌肠见盲肠中线、左位或肝下。     

Left-sided acute appendicitis with intestinal malrotation

Intestinal malrotation is a rare anomaly of rotation and fixation of the midgut. Left-sided appendicitis occurs in association with two types of congenital anomalies, situs inversus and intestinal malrotation. We describe a rare case of left-sided acute appendicitis with intestinal malrotation in a 14-year-old boy, in which computed tomography (CT) was useful for a preoperative diagnosis.     

Midgut volvulus in infants: diagnosis with US. Work in progress

The authors present findings from ultrasound (US) studies that can alert sonologists to the possibility of midgut malrotation complicated by volvulus in neonates and infants. A fluid-filled, distended duodenum seen at US examination in infants is a nonspecific sign of duodenal obstruction, as well as one of the signs of midgut malrotation. In addition, dilated, thick-walled bowel loops, mainly to the right of the spine, and peritoneal fluid were found at abdominal US examinations of three infants with midgut malrotation complicated by volvulus. In one infant with uncomplicated midgut malrotation, only signs of duodenal obstruction were present. The findings at US of duodenal obstruction associated with thickened bowel loops to the right of the spine and peritoneal fluid should lead the sonologist to suspect midgut malrotation complicated by volvulus, a potentially fatal condition, and an upper gastrointestinal series should then be performed to confirm the diagnosis.     

Midgut volvulus in an adult patient with malrotation and abdominal heterotaxia: a case report

Midgut volvulus is rare in adulthood and if not diagnosed accurately, carries a high mortality rate. We present a case of a young adult man who presented with acute abdominal pain and was found to have malrotation with abdominal heterotaxia. Abdominal computed tomography can identify anomalies associated with intestinal malrotation. With the awareness of the potential for malrotation to predispose to midgut volvulus, the patient and his physician will have a higher index of suspicion when abdominal pain occurs. Appropriate treatment of midgut volvulus will reduce morbidity and mortality.     

Left-sided appendicitis revealing a common mesentery: A Case Report

Intestinal malrotation is a congenital rotational anomaly that results of abnormal rotation of the gut, said to occur in 1 in 6000 live births. Common mesentery predisposes to volvulus of the midgut and internal hernias due to the left position of the cecum and appendix. The association of this anomaly with acute left appendicitis is rarely reported in the literature. Occurrence of acute appendicitis on common mesentery is a source of diagnosis difficulties, which may lead to a surgical management delay. We report a case of a 10-year-old boy, admitted for a left-sided iliac pain whose radiological investigations confirmed a left acute appendicitis associated with complete common mesentery. The child underwent laparoscopic surgery with simple post-operative follow-up.     

Polysplenia associated with semiannular pancreas

We report CT images of an asymptomatic, adult case of polysplenia syndrome associated with semiannular pancreas, intestinal malrotation, preduodenal portal vein, and agenesis of the upper abdominal segment of the inferior vena cava with azygous continuation. This rare combination of abdominal abnormalities would be mainly caused by congenital malrotation of lower abdominal organs.     

MRI findings of vestibulocochlear hemorrhage in a leukemic patient with sensorineural hearing loss

This case report presents a patient with M4 leukemia with signs and symptoms of acute sensorineural hearing loss. The patient's MRI demonstrated high signal on unenhanced T1-weighted images within the left vestibulocochlear complex that was consistent with subacute hemorrhage. Follow-up MRI showed clearing of the previously seen high T1-weighted signal from the left vestibulocochlear complex. This case report documents for the first time the MRI findings of vestibulocochlear complex hemorrhage in a leukemic patient.     

成人肠旋转不良及Ladd带致中肠扭转与十二指肠梗阻:病例报告与文献复习

目的探讨成人肠旋转不良及Ladd带致中肠扭转与十二指肠梗阻的临床表现、影像特征及鉴别诊断。方法分析1例成人肠旋转不良及Ladd带致中肠扭转与十二指肠梗阻病人的临床及影像资料,并复习相关文献。结果 CT平扫示胃及十二指肠上段、降段扩张,水平段管腔局部狭窄。CT血管成像示局部肠系膜及肠管围绕肠系膜上动脉顺时针旋转,呈"漩涡征"。手术证实为成人肠旋转不良及Ladd带致中肠扭转与十二指肠梗阻。结论成人肠旋转不良及Ladd带致中肠扭转与十二指肠梗阻为一种罕见疾病,其临床表现缺乏特异性,术前误诊率较高,影像检查具有一定提示作用,大多需手术证实。     

Case report: volvulus of a mesenteric cyst--an unusual complication diagnosed by CT.

A 10-year-old girl presented with colicky abdominal pain and a vague left sided mass on physical examination. Plain radiographs of the abdomen were unremarkable but ultrasound examination demonstrated a large right sided unilocular cystic abdominal mass. Computed tomographic features were diagnostic of volvulus of the proximal small bowel with associated mesenteric cyst. Surgery confirmed CT findings and no mid gut malrotation was noted at operation.     

Sclerosing stromal tumor of the ovary with torsion. MRI features

Sclerosing stromal tumors are rare benign ovarian neoplasms that are usually diagnosed in the second or third decade of life. Most patients with these tumors present with menstrual irregularities and pelvic pain. We present the magnetic resonance imaging (MRI) findings of a left ovarian sclerosing stromal tumor with torsion that was located in the right parauterine area, and discuss the differential diagnosis for this entity based on MRI findings. In this case, MRI demonstrated a well-defined, predominantly solid mass with a pseudolobular pattern, and showed a shift of the uterus to the left. The surgical and histopathologic aspects of the case are also described.     

Unilateral temporalis muscle hypertrophy with contralateral masseteric hypertrophy

We report the MRI findings of a 22-year-old woman who complained of localized swelling in the left temporal region and right side of the face. MRI revealed left temporal and right masseter muscle hypertrophy, which to our knowledge has not been reported previously. The diagnosis of benign masticatory muscle hypertrophy was confirmed by biopsy.     

婴儿肠旋转不良影像学检查的探讨

目的:探讨婴儿肠旋转不良影像学检查的价值.方法:回顾性分析41例经手术证实的婴儿肠旋转不良患者的病例资料.所有病例均摄腹部平片,16例行钡剂灌肠,18例行钡餐检查.结果:腹部平片显示十二指肠部分性梗阻32例,双泡征13例,小肠低位梗阻并腹腔积液3例,未见明显异常3例.钡剂灌肠显示阑尾位于右上腹10例,右中腹1例,左上腹4例,1例位置正常;与手术中记录的阑尾位置比较,诊断符合率较低(28.6%,4/14).钡餐检查显示十二指肠水平段及其近端扩张、梗阻,扩张远端呈鼠尾状改变6例,其中2例显示为完全性梗阻;十二指肠空肠曲位置异常11例;十二指肠螺旋型下降13例;空肠位于右侧腹9例,位置正常1例.结论:在肠旋转不良影像学检查中,腹部平片能提供肠道气体的异常信息,可作为本病的首诊检查方法;钡剂灌肠虽然可显示阑尾位置异常,但诊断准确性低,胃肠钡餐检查可显示十二指肠的位置和形态,是确诊本病的较好影像学方法.     

Complete common mesentery revealed by acute perforated appendicitis: case report and review of the literature

Intestinal malrotation in children is a rare aberration, due to a halt in the rotation and attachment of the primitive gut, it can be asymptomatic if the rotation terminates at 90 degrees, which manifests itself in unusual forms of appendicitis as in our observation, or dangerous in cases of inadequate common mesentery and worsened by small intestine volvulus. This 12-year-old boy experienced abdominal discomfort in the hypogastrium and left iliac fossa 4 days before admission. The pain had been developing in a feverish setting, and the clinical examination had revealed abdominal sensitivity. A biological inflammatory syndrome was detected throughout the biological workup, the CT scan allowed the diagnosis of acute appendicitis on a complete common mesentery, and the patient underwent a laparotomy appendectomy. Even though children frequently experience acute appendicitis in its conventional form, it is nevertheless highly challenging to identify in its atypical forms when intestinal malrotation is involved. An abdominopelvic CT scan is used to make the diagnosis, and appendectomy, preferably with laparoscopy, is the recommended course of action.