Duodenal imaging on the spotlight: from A to Z

Abdominal computed tomography (CT) is frequently performed to evaluate gastrointestinal pathologic conditions. The majority of the gastrointestinal radiology literature has concentrated on the colon, stomach, and distal small bowel. The duodenum is often overlooked on imaging, namely on CT, but its anatomy (intra and retroperitoneal) and location in such close proximity to other viscera results in involvement by a multitude of primary and secondary processes, some of them exclusive to this bowel segment. While some conditions, like duplications, lipomas, and diverticula, are usually asymptomatic and are incidentalomas that have no pathologic significance, others are symptomatic and very relevant and should be recognized by every general radiologist: development conditions such as annular pancreas and gut malrotation; inflammatory processes such as ulcers and secondary involvement from pancreatitis; neoplastic conditions such as adenocarcinoma, lymphoma, or local extension from adjacent malignancies. They all can be reliably diagnosed with CT. In this article, we demonstrate the typical imaging features of various diseases involving the duodenum, such as developmental, traumatic, inflammatory, infectious, neoplastic, and postsurgical pathologic conditions in alphabetical order, focusing mainly on upper gastrointestinal series (UGIS) and CT but also some radiography, ultrasound, and magnetic resonance (MR) imaging.

Abnormal Orientation of the Superior Mesenteric Vessels Detected in Asymptomatic Infants: What Is Its Destiny?

Background: Ultrasonography (USG) has been described as an alternative diagnostic tool for malrotation that evaluates the orientation of the superior mesenteric vessels. However, literature concerning the management of patients who do not have abdominal symptoms is limited. We aimed to review the clinical course of infants showing abnormal orientation of the superior mesenteric vessels on USG who were asymptomatic at the time of diagnosis.Methods: Seventy asymptomatic infants with abnormal orientation of the superior mesenteric vessels in a single center between 2014 and 2018 were retrospectively analyzed.Results: The 70 patients, 21 underwent upper gastrointestinal series (UGIS) and 11 underwent abdominal surgery for other surgical conditions. Among the 32 (45.7%) patients who underwent UGIS or abdominal surgery, 11 were proven to have malrotation. Of the 38 (54.3%) patients who did not undergo UGIS or abdominal surgery, six patients were too unstable to undergo UGIS, five died due to cardiac complications, and the remaining patient developed midgut volvulus and died 3 days after emergency surgery. The remaining 32 patients who did not undergo UGIS or abdominal surgery were discharged without additional tests, and all were asymptomatic until their last follow-up. In the multivariate analysis, history of heart surgery and the presence of more than three anomalies were significantly associated with malrotation.Conclusion: A significant number of malrotation were diagnosed in asymptomatic infants with abnormal orientation of the superior mesenteric vessels on USG. Infants with major cardiac or multiple anomalies need special attention and should undergo UGIS in a promptly manner to confirm malrotation.

Factors That Impact the Timing and Removal of Gastrostomy Placement/Nissen Fundoplication in Children with Bronchopulmonary Dysplasia

Objective The study aimed to identify factors that impact timing of gastrostomy placement/removal and Nissen fundoplication (NF) in infants with bronchopulmonary dysplasia (BPD). Study Design Clinical data were reviewed retrospectively from patients recruited from the Johns Hopkins Bronchopulmonary Dysplasia Clinic (January 1, 2014–December 31, 2018). Results Patients with gastrostomy tubes (GTs) placed in the neonatal intensive care unit (NICU) were older at discharge (p < 0.001) and less likely to have abnormal upper gastrointestinal series findings (p = 0.005) than those with GTs placed after NICU discharge. Patients with NF had lower mean gestational ages (p = 0.011), longer NICU stays (p = 0.019), more frequent home ventilation requirements (p = 0.005), and greater likelihood of pulmonary hypertension (p = 0.032) compared with those without. Median age of GT removal was 61.6 months. Patients with GTs were weaned from supplemental oxygen and/or home ventilation before GT removal (p < 0.001). Conclusion Patients with GT/NF were more medically complex than those with GT alone. Patients were more likely to be weaned from home respiratory support before GT removal. Key Points

Annular pancreas causing pyloric stenosis in a 66-year-old patient treated with gastrojejunostomy: a case report

Annular pancreas is defined by a ring of pancreatic tissue encircling the descending portion of the duodenum. It is exceptionally rare in adults and commonly diagnosed during the investigation of symptoms arising due to its complications. Treatment usually involves the surgical correction with a duodenoduodenostomy, gastrojejunostomy or duodenojejunostomy. We discuss the case of a 66-year-old male patient who presented with symptoms of gastric outlet obstruction and was found to have an annular pancreas encircling the pylorus and the first and second portions of the duodenum and was treated by performing a gastrojejunostomy. Upper gastrointestinal series, computerized tomography (CT) scans, and magnetic resonance cholangeopancreatographys can all be used for preoperative diagnosis; however, endoscopic retrograde cholangiopancreatography (ERCP) is the diagnostic modality of choice. Nonetheless, many patients may only be diagnosed intraoperatively, especially those who cannot undergo an ERCP due to stenosis proximal to the duodenum or patients in whom the annulus may not be visible on CT scan.

La malrotazione intestinale: cosa deve sapere il pediatra

Intestinal malrotation includes anomalies of intestinal rotation and fixation occurred during embryogenesis. It may present with acute or chronic-intermittent symptoms or remain asymptomatic. There are several methods to identify a defect of intestinal rotation, however an upper gastrointestinal series remains the method of choice in non-acute cases. Surgical correction is performed by open laparotomy, while the laparoscopic approach is reserved only to selected cases. This article suggests an evaluation of children with suspected intestinal malrotation and gives information about its management and complications to paediatricians.

Paralytic ileus in the neonate as a rare complication of maternal methadone treatment—a case report

Narcotic bowel syndrome is defined as worsening abdominal bloating and cramping with chronic opiate use, leading to paralytic ileus. This syndrome is common yet underreported in adults. However, there is no current evidence of such conditions in the newborn after exposure in utero to high doses of opiates. Our patient was a female indigenous preterm infant born to a mother on a high dose of methadone. On admission at the age of 12 h, she was found to have significant gastric distension. Initial abdominal X-ray showed a large gastric bubble with little evidence of rectal gas. Malrotation was suspected and surgical intervention was discussed. However, repeat abdominal X-ray, ultrasound and upper Gastrointestinal series were found to be normal and without acute findings. Thus, surgery was avoided. The gastric distension resolved spontaneously. She never required opiate therapy for neonatal abstinence syndrome. Given the pattern of gas seen on the initial abdominal X-ray and its spontaneous resolution after removal of maternal methadone, we suspect this baby had neonatal narcotic bowel syndrome. This has never been reported in the literature and is a unique finding. Given the lack of current reports, further observations for this syndrome should be conducted.

Upper gastrointestinal series in children: what surgeons need to know

Background Upper gastrointestinal (UGI) series is the standard imaging tool for diagnosis of structural and functional abnormalities affecting the esophagus, stomach, and proximal small bowel. The aim of this study was to delineate the clinical indications for UGI series in children that are associated with the presence of significant radiological abnormalities aiming for more standardized care for those patients. Results UGI series of 118 patients was analyzed with calculation of clinical score. Vomiting was the most frequent primary complaint (63.6%), followed by dysphagia and recurrent chest infection. Forty-nine patients had positive upper GI findings (42%). The most detected abnormality was related to the stomach and duodenum (21.4%). Variable degrees of idiopathic gastroesophageal reflux were detected in 16 patients (13.6%). Patients with clinical score 2 or more had significantly more prevalence of abnormal findings (p = .001). Vomiting (especially when bilious), underweight, aspiration, and recurrent chest infection were strong predictors of abnormal findings on upper GI series (p = 0.007, 0.001, 0.009, and 0.001, respectively) and increased the diagnostic yield of upper GI series for detection of abnormalities by 3.48, 9.6, 4, and 4.12 times, respectively. Conclusion Diagnostic yield of UGI series was relatively higher in patients having two or more symptoms (clinical score 2 or more) and in children with bilious vomiting, aspiration and underweight, or repeated chest infection.