Midgut Malrotasyon ve Volvulus

◆Ayırıcı Tanı İpuçları

• 1US'de 'whirlpool sign' — SMA etrafında dönen SMV ve mezenter (volvulus için patognomonik)
• 2US'de SMA/SMV pozisyon tersliği — SMV normalin aksine SMA'nın solunda veya anteriorunda (malrotasyon işareti)
• 3UGI'de DJ junction sağda veya midline'da — malrotasyon için altın standart tanı (duyarlılık >%95)
• 4Yenidoğanda biliyöz (safralı, yeşil) kusma — volvulus ekarte edilene kadar malrotasyon-volvulus kabul edilmeli
• 5UGI'de 'corkscrew sign' (burgu işareti) — duodenum/jejunumun spiral konfigürasyonu (volvulus)

♦Patofizyoloji

Diferansiyel İpuçları

• →Duodenal atrezi: double bubble sign, safralı kusma ama volvulus yok, Down sendromu ilişkisi
• →Jejunal/ileal atrezi: triple/multiple bubble sign, proksimalde daha fazla dilatasyon
• →Pilor stenozu: safrasız projektil kusma, pilorik kas hipertrofisi, 2-8 hafta
• →NEK: prematüre, pnömatozis intestinalis, portal venöz gaz

●Klinik Önem

Neonatal dönemin en acil cerrahi durumlarından biridir. Safralı (yeşil) kusma ile prezente olan her yenidoğanda malrotasyon/volvulus ekarte edilmelidir — tanı gecikmesi intestinal nekroz, kısa bağırsak sendromu ve ölüme yol açabilir. US'de whirlpool sign hızlı tanı sağlar. Acil Ladd prosedürü hayat kurtarıcıdır. Vasküler kompromise gelişmeden cerrahi yapıldığında prognoz mükemmeldir. Gecikmiş olgularda masif bağırsak nekrozu gelişebilir.

Kaynaklar

• Defined by Defined by Defined by Defined by Defined by Defined by ACR Appropriateness Criteria: Vomiting in Infants Up to 3 Months of Age. 2021.
• Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Orzech N, et al. Is ultrasonography a good screening test for intestinal malrotation? J Pediatr Surg. 2006;41(5):1005-9.
• Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Strouse PJ. Disorders of intestinal rotation and fixation ('malrotation'). Pediatr Radiol. 2004;34(11):837-51.
• Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Sizemore AW, et al. Diagnostic performance of the upper gastrointestinal series for midgut malrotation in pediatric patients. Pediatr Radiol. 2008;38(5):518-28.
• Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Torres AM, Ziegler MM. Malrotation of the intestine. World J Surg. 1993;17(3):326-31.