Document Detail

Intrauterine volvulus of terminal ileum without malrotation.
Jump to Full Text
MedLine Citation:
PMID:  24404409     Owner:  NLM     Status:  PubMed-not-MEDLINE    
Neonatal terminal ileum volvulus in the absence of malrotation has never been reported before in English literature. However, another similar rare entity known as neonatal primary segmental volvulus without malrotation has been reported before. Volvulus, in general, is an extreme emergency and cases not diagnosed in time lead to death. The main diagnosis is based on radiological features seen on imaging. We present a case of volvulus of terminal ileum that was diagnosed and surgically treated at age of 15 h ensuring the newborn survived. The definitive diagnosis was based mainly on ultrasonographic findings.
Suheil Artul; George Habib; Amin Adawi; Bishara Mansour; William Nseir
Related Documents :
22676829 - Localized mandibular enlargement in end-stage renal disease: two case reports and a rev...
8740959 - A critical review of chinese koro.
22498429 - Decisions about lumping vs. splitting of the scope of systematic reviews of complex int...
22720749 - Radiotherapy and bevacizumab for intramedullary and leptomenigeal metastatic glioblasto...
11852299 - Pramipexole ameliorates neurologic and psychiatric symptoms in a westphal variant of hu...
23508659 - Provisional report on diving-related fatalities in australian waters 2008.
14768469 - Evaluation of percutaneous endoscopic gastrostomy in elderly patients with silicosis an...
387209 - Metastatic melanoma of the gallbladder.
21626019 - Headache during airplane travel ("airplane headache"): first case in greece.
Publication Detail:
Type:  Journal Article     Date:  2013-11-28
Journal Detail:
Title:  Journal of clinical imaging science     Volume:  3     ISSN:  2156-7514     ISO Abbreviation:  J Clin Imaging Sci     Publication Date:  2013  
Date Detail:
Created Date:  2014-01-09     Completed Date:  2014-01-09     Revised Date:  2014-01-24    
Medline Journal Info:
Nlm Unique ID:  101564708     Medline TA:  J Clin Imaging Sci     Country:  United States    
Other Details:
Languages:  eng     Pagination:  50     Citation Subset:  -    
Export Citation:
APA/MLA Format     Download EndNote     Download BibTex
MeSH Terms

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

Full Text
Journal Information
Journal ID (nlm-ta): J Clin Imaging Sci
Journal ID (iso-abbrev): J Clin Imaging Sci
Journal ID (publisher-id): JCIS
ISSN: 2156-7514
ISSN: 2156-5597
Publisher: Medknow Publications & Media Pvt Ltd, India
Article Information
Copyright: © 2013 Artuel S.
Received Day: 17 Month: 6 Year: 2013
Accepted Day: 09 Month: 10 Year: 2013
collection publication date: Year: 2013
Electronic publication date: Day: 28 Month: 11 Year: 2013
Volume: 3E-location ID: 50
PubMed Id: 24404409
ID: 3883270
Publisher Id: JCIS-3-50
DOI: 10.4103/2156-7514.122317

Intrauterine Volvulus of Terminal Ileum Without Malrotation
Suheil Artul12
George Habib5
Amin Adawi3
Bishara Mansour4
William Nseir25
1Department of Radiology, Nazareth Hospital, Safed, Israel
2Department of Radiology, Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
3Department of Neonatal, Nazareth Hospital, Nazareth, Israel
4Pediatric Surgery Unit, Nazareth Hospital, Nazareth, Israel
5Department of Medicine, Nazareth Hospital, Nazareth, Israel
Correspondence: Address for correspondence: Dr. Suheil Artul, Department of Radiology, Nazareth Hospital, Edinburgh Medical Missionary Society, Nazareth, Israel. E-mail:


Majority of neonatal midgut volvulus cases are due to malrotation. Some other causes can be due to postoperative adhesions, duplication cyst, meconium “ileus”, and internal hernia.[1] According to our knowledge, this is the first report of intrauterine volvulus of terminal ileum without malrotation that was diagnosed by ultrasound.

Our case deals with terminal ileum torsion around its axis with twisting of mesenteric vessels. Torsion, in general, leads to necrosis of the involved bowel segment. Therefore, it is of medical importance to recognize the radiological signs of bowel torsion as soon as possible. We present a case of volvulus of terminal ileum which was diagnosed and treated surgically in a neonate just 15 h after delivery.


A female baby was born preterm at 35-weeks, with parameters appropriate for her gestational age, weighing 2666 g, with APGAR 9-10 at 1 and 10 min, respectively. Maternal history provided a previous missed abortion, otherwise the mother was a healthy woman who had a normal pregnancy and normal fetal screening follow-up findings. On physical examination of the preterm baby done immediately after delivery revealed a distended abdomen and some grunting. Investigational work-up was started including, chest X-ray which was normal, arterial blood gases showed mild metabolic acidosis, blood and urine culture were obtained, and wide spectrum intravenous antibiotics were started. The baby was referred to our radiological department for plain abdominal X-ray at age of 2 h. The X-ray showed a distended and gasless abdomen, except for a small amount of air in the stomach [Figure 1].

This radiological finding might be normal at this age, but since the baby was crying it was assumed to have more air in the intestine. The radiological finding raised the possibility of intestinal obstruction. Thus, we started an upper gastrointestinal study to rule out any cause of intestinal obstruction.

The barium study ruled out a malrotation showing a normal gastric, duodenal, and normal location of the Treitz ligament [Figure 2]. Two hours after the start of the barium study, we noticed lack of propagation of the barium at the level of right lower quadrant of the abdomen. This led us to suspect ileal atresia, which is the most common cause of obstruction after malrotation.[2] After 13 h, a small bowel loop showed a “bird beak” sign with filling defect and a round structure around this end loop [Figure 3]. This radiological finding suggested ileal obstruction due to volvulus with presumed duplication cyst as the leading point.

Immediate ultrasonographic examination of the abdomen was done to confirm the diagnosis. Ultrasound scan showed a target lesion consistent of two loops of bowel, pneumatosis of the bowel wall, and twisting of vessels [Figure 4], suggesting a diagnosis of ileal volvulus with intestinal ischemia. The baby was operated on immediately. Intraoperative findings showed volvulus of terminal ileum with intestinal ischemia and perforation with free meconium in the abdomen. We think that meconium in this case was the main predisposing factor for the volvulus of this baby. A resection of the suffered terminal ileum was done with protective ileostomy. The postoperative follow-up revealed a satisfactory clinical course.


According to our knowledge, this is the first case of intrauterine volvulus of terminal ileum without malrotation, that was diagnosed definitively by ultrasound and operated on within a few hours after birth thus saving the life of the baby.

Congenital volvulus is a life-threatening condition for the newborn. Neonatal volvulus is secondary to malrotation, and involves twisting of bowel loop with its feeding vessels that leads to ischemia, necrosis, and perforation with fatal complication, if not recognized and treated in time. Intestinal volvulus without malrotation occurs in 19%-20% of the small bowel volvulus in children.[2, 3] The etiology of neonatal volvulus without malrotation remains unknown. However, other rare predisposing causes are Meckel's diverticulum, duplication cyst, and meconium plug. Delayed diagnosis can lead to significant morbidity and mortality.[4]

Diagnosis of volvulus in any suspected neonatal intestinal obstruction by plain film and barium study is extremely difficult especially when malrotation is ruled out. The most common causes of these cases of intestinal obstruction are intestinal atresia that is fatal in the first hours of life if not treated immediately.


Based on our case, we suggest: In any case of suspected intestinal obstruction, first we have to rule out intestinal malrotation with an upper gastrointestinal barium study. Once malrotation is ruled out, we suggest immediately performing an ultrasound examination of the abdomen to rule out an ileal volvulus.

Late diagnosis in volvulus could be fatal. Thus, ultrasound examination that shows a target lesion “bird beak” sign of the involved bowel allows to quickly identify this morbid entity without loss of precious time.


Available FREE in open access from:

Source of Support: Nil

Conflict of Interest: None declared.

1. Lampl B,Levin TL,Berdon WE,Cowles RA. Malrotation and midgut volvulus: A historical review and current controversies in diagnosis and managementPediatr RadiolYear: 2009393596619241073
2. Kitano Y,Hashizume K,Okhura M. Segmental small bowel volvulus not associated with malrotation in childhoodPediatr Surg IntYear: 1995103358
3. Berrocal T,Lamas M,Gutieerrez J,Torres I,Prieto C,del Hoyo ML. Congenital anomalies of the small intestine, colon, and rectumRadiographicsYear: 19991912193610489177
4. Kornacki J,Czarnecka M,Blaszczynski M,Skrzypczak J,Gadzinowski J,Jankowski A,Sardesai S. Congenital midgut volvulus associated with fetal anemiaFetal Diagn TherYear: 2010281192220616522


[Figure ID: F1]
Figure 1 

Female baby at 2 h after birth with distended abdomen diagnosed with intrauterine volvulus of terminal ileum without malrotation. X-ray of abdomen shows distended and gasless abdomen except a small amount of air in the stomach (black arrow).

[Figure ID: F2]
Figure 2 

Female baby at 2 h after birth with distended abdomen diagnosed with intrauterine volvulus of terminal ileum without malrotation. Barium study shows normal location of Trieitz ligament (black arrow).

[Figure ID: F3]
Figure 3 

Female baby at 13 h after birth with distended abdomen diagnosed with intrauterine volvulus of terminal ileum without malrotation. At 13 h, the barium study shows stopage of barium with a beak-like shape of the pre-obstructed bowel (black arrow) with filling defect(white arrow) and a structure containing air around the end loop (arrowheads)

[Figure ID: F4]
Figure 4 

Female baby at 13 h after birth with distended abdomen diagnosed with intrauterine volvulus of terminal ileum without malrotation. Ultrasonographic examination of the abdomen shows a target lesion consistent with two loops of bowel, pneumatosis of the bowel wall (arrowheads) and twisting of vessels (white arrow).

Article Categories:
  • Case Report

Keywords: Malrotation, ultrasound, volvulus terminal ilium.

Previous Document:  Project nGage: Network Supported HIV Care Engagement for Younger Black Men Who Have Sex with Men and...
Next Document:  Vena caval anomalies.