Neonatal malrotation very seldom mimics duodenal atresia. A gastric Replogle tube was placed, and approximately 70 mL of green bile–stained fluid was removed from the stomach. It is particularly important to recognize intestinal malrotation and midgut volvulus as mimics of the double-bubble sign. Intestinal malrotation is a birth defect involving a malformation of the intestinal tract that occurs while a fetus is forming in its mother's uterus. [4] found a very low false-negative rate (2%) with ultrasound. 4A) showed a double-bubble sign. Other causes include malrotation with midgut volvulus, duodenal web (windsock deformity), annular pancreas, preduodenal portal vein, and duodenal hematoma. 1). Bilious vomiting with or without abdominal distention may be the initial clinical finding in all of these entities and is often not differentiating. Copyright © 2013-2020, American Roentgen Ray Society, ARRS, All Rights Reserved. We report the cases of four neonates with the double-bubble sign as a rare radiographic manifestation of midgut volvulus. The abdomen was soft, nontender, and slightly distended. Duodenal Stenosis (With Annular Pancreas) Partial duodenal obstruction in neonates is usually caused by duodenal stenosis, with or without annular pancreas. A A B B C C. REVIEW There is no gas in the bowel distal to the dilated duodenum. Keywords: double-bubble sign, duodenal atresia, malrotation, midgut volvulus. In the other two patients, surgery was delayed 2–5 days, likely because of the clinical stability of the patients' conditions combined with the initial imaging findings suggesting duodenal atresia. Double Bubble Sign. CONCLUSION. Neonatal Intestinal Obstruction, Clinical Observations. On day 11 of life, the surgical finding was malrotation with midgut volvulus. Because the clinical and radiographic presentation of malrotation and midgut volvulus can be problematic [2], we suggest that when surgery will be delayed, a screening ultrasound or upper GI study be performed on any patient with radiographic evidence of high-grade duodenal obstruction. It is particularly important to recognize intestinal malrotation and midgut volvulus as mimics of the double-bubble sign. The double-bubble sign is highly suggestive of duodenal atresia; however, other causes of high-grade duodenal obstruction can mimic the sign on kidneys, ureters, bladder radiographs. APPEARANCE The double bubble sign is a finding observed on radiographs of newborns and infants ( Fig 1 ). It is particularly important to recognize intestinal malrotation and midgut volvulus as mimics of the double-bubble sign. The patient underwent surgery, during which no ischemic bowel was found, and a Ladd procedure was performed. When there is gas distal to the dilated proximal duodenum, malrotation must be distinguished from duodenal stenosis by ultrasound or an upper GI study. Orzech et al. A plain x-ray of the abdomen may show the characteristic "double bubble sign… Malrotation and midgut volvulus were subsequently diagnosed in all four cases. Intraoperatively, we found annular pancreas with malrotation and type I choledochal cyst. Intestinal malrotation without volvulus in infants and children is often difficult to diagnose because of less dramatic clinical features, e.g. the classic “double bubble sign” (Fig. An X-ray of the abdomen shows two large air filled spaces, the so-called "double bubble" sign. A radiograph showed a double bubble with no distal air (Fig. Double bubble sign with gastric and proximal duodenum distension and no distal air. A boy born at term had bilious return from an orogastric tube and a double bubble on an abdominal radiograph (Figs. The prevalence of duodenal atresia is ~1 in 5,000-10,000 newborns, and there is no sex-associated difference in prevalence. It is seen in both radiographs and ultrasound, and can be identified antenatally 2. Patients with radiographic findings of duodenal atresia for whom surgery will be delayed should undergo an upper GI or ultrasound study in an evaluation for malrotation with midgut volvulus. 1). If severely obstructive may show a double bubble sign. On kidneys, ureters, bladder radiographs, duodenal atresia has a characteristic appearance known as the double-bubble sign. Fluoroscopy. Supine radiograph of the abdomen demonstrates a dilated stomach (S) and an accompanying dilated proximal duodenum (D). An institutionally approved retrospective chart review with review of the imaging and surgical findings was performed on the cases of four patients who between October 2005 and September 2008 had biliary emesis and radiographic findings of high-grade proximal bowel obstruction. Four neonatal patients had bilious emesis and a double-bubble appearance on radiographs, originally thought to represent duodenal atresia. Causes include 1,2: congenital obstruction. Double duodenal atresia and malrotation in a patient with “Cri du Chat” syndrome. Bilious vomiting in newborns is an urgent condition that requires the immediate involvement of a team of pediatric surgeons and neonatologists for perioperative management. When a polyhydramnion and a double bubble are present antenatally, ... Malrotation arises when the rotation is arrested or even reversed. DOUBLE BUBBLE SIGN Duodenal Atresia Malrotation with Ladd’s Bands Annular Pancreas Obstructing Choledochal Cyst Surgery is required but is not urgent. Keywords: double-bubble sign, duodenal atresia, malrotation, midgut volvulus. Metaphyseal Fragmentation with Physiologic Bowing: A Finding Not to Be Confused with the Classic Metaphyseal Lesion. Can typically give a "windsock sign" (gradual ballooning of the duodenal diaphragm) or "halo sign" due to the web projecting caudally into the duodenal lumen. An upper GI series (Figs. failure to thrive and intermittent bile stained vomiting, compared to the patients with volvulus. The double bubble sign indicates the presence of duodenal obstruction that can be caused by a number of intrinsic or extrinsic etiologies.The intrinsic causes include duodenal webs, duodenal atresia, and duodenal stenosis. Midgut volvulus: a rare cause of acute abdomen in an adult patient. Note the "double bubble" sign and narrowing of the second portion of the duodenum; however, the duodenum does cross the midline and it is not twisted. In infants with bilious emesis, plain x-rays of the abdomen should be done immediately. Chest and abdominal radiographs were obtained and revealed the classic double-bubble finding indicative of congenital duodenal atresia. Kidneys, ureters, bladder radiography (Fig. [2,4] An UGI study or other postnatal imaging can be obtained to confirm the exact diagnosis. In the article by Gilbertson-Dahdal et al. Imaging Pulmonary Infection: Classic Signs and Patterns. Malrotation** • Definition: abnormal intestinal rotation and fixation • Occurs in ~ 1-2% of the population • Presentation**: – Symptomatic: bilious emesis, developing to abdominal distention and peritonitis (if untreated) • small bowel obstruction with volvulus Prompt diagnosis of midgut volvulus is important because emergency surgery is needed to prevent the potentially catastrophic complication of intestinal necrosis [1]. An upper gastrointestinal (GI) series showed malrotation with midgut volvulus. 2A and 2B). [4, 5] In a study by Sizemore et al, an upper GI series in the detection of intestinal malrotation in infants and youths had a sensitivity of 96%, providing positive results in 156 of the 163 patients with surgically verified malrotation. The patient was transferred to our institution on day 3 of life. We present a low-birth weight newborn who presented with bilious vomit and had a “double bubble” sign on plain abdominal X-ray. intestinal malrotation; annular pancreas; Radiographic features Plain radiograph. The two patients who appeared the most ill underwent upper GI studies, which showed malrotation and midgut volvulus. However, anything other than this sign should be treated with great suspicion for the presence of malrotation and midgut volvulus. In jejunoileal atresia abdominal distention with bilious DOUBLE BUBBLE SIGN Duodenal Atresia Malrotation with Ladd’s Bands Annular Pancreas Obstructing Choledochal Cyst Surgery is required but is not urgent. malrotation: the double bubble sign is seen with no gas distally. “double bubble” sign. A 24- to 48-hour delay may be allowed before operation for transport, further evaluation and fluid resuscitation. A boy was born via normal spontaneous vaginal delivery at 36 weeks and 1 day of gestation to a 20-year-old, gravida 1, para 1 woman. ... (US) at 21 weeks of gestation showed an intraabdominal double-bubble sign, suggestive of duodenal atresia. Neonatal Malrotation with Midgut Volvulus Mimicking Duodenal Atresia, Pictorial Essay. The appearance is in keeping with malrotation. Intestinal obstruction in the newborn. There was no bowel compromise, and a modified Ladd procedure was performed. It occurs equally in boys and girls. Infants with malrotation and midgut volvulus often are described as having bile-stained emesis, abdominal distention, and peritoneal signs and may appear ill. We examined the cases of four patients with bilious vomiting and a double bubble on radiographs who did not appear markedly ill. All four neonates were found to have malrotation with midgut volvulus. Neonatal Intestinal Obstruction, Review. The classic double-bubble sign is the only true double-bubble sign. The diagnosis can usually be made by a plain x-ray showing a gas-filled stomach and enlarged (dilated) duodenum, but no distal air in the GI tract This is often called a “double bubble sign.” The presence of distal air is concerning for intestinal volvulus and mandates an upper GI to exclude malrotation. There is no gas distal to the duodenal bubble. An initial radiograph showed a double-bubble sign (Fig. Intestinal malrotation is a congenital anatomical anomaly that results from an abnormal rotation of the gut as it returns to the abdominal cavity during embryogenesis.. Supine abdominal radiograph of a newborn presenting with billous vomiting shows a distended stomach and duodenal air bubbles "double bubble" sign. A boy born at term in no distress was placed in the well-baby nursery. Be obtained to confirm the exact diagnosis ARRS, all Rights Reserved newborns, and a Ladd. 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