ClinicalRadiology(1992) 46, 286-287
Case Report: Small Bowel Volvulus Presenting During Pregnancy A. J. L I D D I C O A T
a n d D . C. F. L L O Y D
Department of Diagnostic Radiology, Llandough Hospital, Llandough, South Glamorgan The diagnostic use of ionizing radiation during pregnancy is to be avoided whenever possible due to the risk to the unborn child. However, vomiting presenting after the first trimester of pregnancy is unusual, and if severe or persistent, requires investigation. We present a case where reluctance to expose the fetus to radiation could have resulted in a potentially serious delay in the diagnosis of maternal small bowel volvulus. Liddicoat, A.J. & Lloyd, D.C.F. (1992).
Clinical Radiology
46, 2 8 6 - 2 8 7 . C a s e R e p o r t : S m a l l B o w e l V o l v u l u s P r e s e n t i n g D u r i n g
Pregnancy
CASE REPORT A 23-year-old prima gravida presented at 25 weeks gestation with a 3 day history of vomiting bile-stained fluid and backache. She had passed flatus but no stool for 4 days. On specific questioning there was a long history of episodic abdominal pain. The patient had been investigated for pyloric stenosis at the age of 3 weeks at which time a barium meal had been reported normal. At the age of 21 years she was admitted with suspected appendicitis. Routine appendicectomy was performed via grid iron incision although subsequent histological examination showed that the appendix was normal. On examination, the cardiovascular and respiratory systems were normal. There was no abdominal tenderness or guarding. Uterine fundal height was consistent with gestational dates. A clinical diagnosis of urinary tract infection was made. Blood biochemistry revealed a mild metabolic alkalosis (bicarbonate 34 retool/l, normal range 22-30 mmol/1). There was a polymorph leucocytosis (white cell count 17 x 109/1, 85% neutrophils). A midstream urine sample was bacteriologically negative. A plain abdominal radiograph showed a paucity of bowel gas in the lower abdomen consistent with the presence of the gravid uterus but no evidence of intestinal obstruction. Upper abdominal ultrasound was normal although the pancreas and mesenteric vessels could not be adequately visualized. No fetal, placental or uterine abnormality was demonstrated. The patient was treated conservatively by intravenous hydration and nasogastric intubation. Seven days after admission nasogastric aspirates remained greater than 1 litre a day. Upper gastrointestinal endoscopy was therefore performed which demonstrated a linear oesophageal ulcer considered to be due to the nasogastric tube. Bile-stained fluid was present in the stomach. The first and second parts of the duodenum were normal. Ten days after admission the patient had not settled, and following discussion between obstetric, surgical and radiological teams, a limited barium meal was performed. The patient was intermittently screened (total time of 19 s), and a single radiograph exposed with lead protection for the fetus. This showed dilation of the stomach and proximal two parts of the duodenum, with the third part of the duodenum taking an abnormal course towards the right upper quadrant• The duodenum was completely obstructed at this point (Fig. 1). A diagnosis of small bowel malrotation with duodenal obstruction due to volvulus or peritoneal bands was made. At laparotomy there was midgut malrotation with partial volvulus, extensive adhesions, and a tight band crossing the duodenum, the adhesions were divided and a broad base to the mesentery was created. The patient had an uncomplicated postoperative recovery•
Correspondence to: Dr D. C. F. Lloyd, Department of Diagnostic Radiology, University Hospital of Wales, Heath Park, Cardiff CF4 4XN.
Fig. 1 - The single film from the barium study shows a dilated stomach, with abnormal orientation of the duodenum giving the first coil of a corkscrew appearance. There is complete duodenal obstruction.
DISCUSSION I n t e s t i n a l o b s t r u c t i o n d u e to m i d g u t m a l r o t a t i o n u s u a l l y o c c u r s d u r i n g early c h i l d h o o d , 7 5 % o f cases o c c u r r i n g in t h e first m o n t h o f life [1]. P r e s e n t a t i o n in a d u l t h o o d is r a r e w i t h few r e p o r t s in t h e l i t e r a t u r e [2]. P e r i t o n e a l b a n d s c r o s s i n g the d u o d e n u m a r e a l m o s t a l w a y s p r e s e n t in cases o f o b s t r u c t i v e m a l r o t a t i o n . T h e s e b a n d s a l s o fix t h e p r o x i m a l p o r t i o n o f t h e t r a n s v e r s e c o l o n in the r i g h t u p p e r q u a d r a n t a n d the p o s i t i o n o f t h e c a e c u m c a n t h e r e f o r e b e n o r m a l , t h o u g h it is classically h i g h [3]. T h i s e x p l a i n s t h e r o u t i n e i n c i s i o n f o r a p p e n d i c e c t o m y in this case. The diagnosis can be made on upper gastrointestinal contrast examinations by demonstrating that the duod e n o - j e j u n a l flexure d o e s n o t lie in its e x p e c t e d p o s i t i o n in t h e left u p p e r q u a d r a n t o f t h e a b d o m e n [4]. T h e d i a g n o s i s is easily m i s s e d u n l e s s t h e f o u r t h p a r t o f t h e d u o d e n u m is e x a m i n e d w i t h this d i a g n o s i s in m i n d . I n this case a
SMALL BOWEL VOLVULUS DURING PREGNANCY
barium m e a l p e r f o r m e d during the neonatal period was said to have been normal. It has recently been d e m o n strated that diagnosis o f malrotation can be m a d e sonographically by demonstrating the superior mesenteric vein to lie anterior or to the left o f the superior mesenteric artery [5]. However, a barium study will usually be necessary to confirm that this has caused obstruction, and to identify the level o f obstruction. With the increasing use o f ultrasound to diagnose pyloric stenosis in vomiting babies, it is important to remember the possibility o f m a l r o t a t i o n and if possible note the relationship o f the superior mesenteric vessels. D u r i n g early pregnancy 50% of w o m e n complain o f nausea, and one third o f these vomit. H o w e v e r such s y m p t o m s usually settle towards the end o f the first trimester. In cases o f severe or persistent vomiting, particularly if this begins after the first trimester, it is important to exclude intestinal obstruction [6]. Intestinal obstruction in pregnancy is m o s t c o m m o n l y caused by adhesions, followed by volvulus, with small bowel volvulus accounting for just under 7% o f all cases [7]. Finding an increase in the incidence o f volvulus towards the end o f pregnancy, H a r e r and H a r e r [7] concluded that displacement o f bowel can precipitate obstruction and that the presence o f the gravid uterus might prevent spontaneous reduction. Unfortunately, t h o u g h they state that an underlying congenital abnormality was present in 25% o f patients with volvulus, the specific incidence of m a l r o t a t i o n is not mentioned. The N a t i o n a l Radiological Protection Board [8] estimates the probability o f induction o f a childhood cancer following an average barium meal performed during pregnancy (a dose to the pelvis o f 3.6 m G y ) to be approximately 1 in 4500. This compares to a natural incidence o f 1 in 1800 [9]. The risk can be reduced by
287
performing a limited examination, with careful attention to screening time, collimation o f the X - r a y beam, and a single radiograph using a cassette with rare earth screens to record any abnormality. Whenever possible, diagnostic radiation during pregnancy should be avoided [10]. W h e n radiological investigation is indicated, this should be performed promptly, with care to m i n i m i z e radiation dose to the fetus. Delay in the diagnosis o f volvulus can lead to ischaemic bowel, endangering the health and life o f m o t h e r and fetus [7].
REFERENCES
l Berdon WE, Baker DH, Bull S, Santulti TV. Midgut malrotation and volvulus. Which films are most helpful? Radiology 1970;96:375383. 2 Wang C, Welch C. Anomalies of intestinal rotation in adolescents and adults. Surgery 1963;54:839-855. 3 Girdany BR. The abdomen and gastrointestinal tract. In: Caffey's pediatric X-ray diagnosis', 8th ed. Chicago: Year Book Medical Publishers Inc., 1985:1481. 4 Alford BA, Keats TE. The gastrointestinal tract; The newborn and young infant. In: Grainger RG & Allison DJ, eds. Diagnostic radiology. Edinburgh: Churchill Livingstone, 1986:912-913. 5 Gaines PA, Saunders AJS, Drake D. Midgut malrotation diagnosed by ultrasound. Clinical Radiology 1987;38:51-53. 6 Hibbard BM. Gastrointestinal function and dysfunction. In: Principles of obstetrics. London: Butterworths, 1988:227 242. 7 Harer WB, Harer WB. Volvulus complicating pregnancy and puerperium. Obstetrics and Gynaceology 1958;12:399-406. 8 Patient dose reduction in diagnostic radiology. National Radiological Protection Board. London: HMSO, 1990. 9 Russell JGB. Diagnostic radiation, pregnancy and termination (letter). British Journal of Radiology 1989;62:92-94. 10 Exposure to ionising radiation of pregnant women; advice on the diagnostic exposure of those who are, or may be pregnant. National Radiological Protection Board. London: HMSO, 1985.
Case Report: Small Bowel Volvulus Presenting During Pregnancy A. J. L I D D I C O A T
a n d D . C. F. L L O Y D
Department of Diagnostic Radiology, Llandough Hospital, Llandough, South Glamorgan The diagnostic use of ionizing radiation during pregnancy is to be avoided whenever possible due to the risk to the unborn child. However, vomiting presenting after the first trimester of pregnancy is unusual, and if severe or persistent, requires investigation. We present a case where reluctance to expose the fetus to radiation could have resulted in a potentially serious delay in the diagnosis of maternal small bowel volvulus. Liddicoat, A.J. & Lloyd, D.C.F. (1992).
Clinical Radiology
46, 2 8 6 - 2 8 7 . C a s e R e p o r t : S m a l l B o w e l V o l v u l u s P r e s e n t i n g D u r i n g
Pregnancy
CASE REPORT A 23-year-old prima gravida presented at 25 weeks gestation with a 3 day history of vomiting bile-stained fluid and backache. She had passed flatus but no stool for 4 days. On specific questioning there was a long history of episodic abdominal pain. The patient had been investigated for pyloric stenosis at the age of 3 weeks at which time a barium meal had been reported normal. At the age of 21 years she was admitted with suspected appendicitis. Routine appendicectomy was performed via grid iron incision although subsequent histological examination showed that the appendix was normal. On examination, the cardiovascular and respiratory systems were normal. There was no abdominal tenderness or guarding. Uterine fundal height was consistent with gestational dates. A clinical diagnosis of urinary tract infection was made. Blood biochemistry revealed a mild metabolic alkalosis (bicarbonate 34 retool/l, normal range 22-30 mmol/1). There was a polymorph leucocytosis (white cell count 17 x 109/1, 85% neutrophils). A midstream urine sample was bacteriologically negative. A plain abdominal radiograph showed a paucity of bowel gas in the lower abdomen consistent with the presence of the gravid uterus but no evidence of intestinal obstruction. Upper abdominal ultrasound was normal although the pancreas and mesenteric vessels could not be adequately visualized. No fetal, placental or uterine abnormality was demonstrated. The patient was treated conservatively by intravenous hydration and nasogastric intubation. Seven days after admission nasogastric aspirates remained greater than 1 litre a day. Upper gastrointestinal endoscopy was therefore performed which demonstrated a linear oesophageal ulcer considered to be due to the nasogastric tube. Bile-stained fluid was present in the stomach. The first and second parts of the duodenum were normal. Ten days after admission the patient had not settled, and following discussion between obstetric, surgical and radiological teams, a limited barium meal was performed. The patient was intermittently screened (total time of 19 s), and a single radiograph exposed with lead protection for the fetus. This showed dilation of the stomach and proximal two parts of the duodenum, with the third part of the duodenum taking an abnormal course towards the right upper quadrant• The duodenum was completely obstructed at this point (Fig. 1). A diagnosis of small bowel malrotation with duodenal obstruction due to volvulus or peritoneal bands was made. At laparotomy there was midgut malrotation with partial volvulus, extensive adhesions, and a tight band crossing the duodenum, the adhesions were divided and a broad base to the mesentery was created. The patient had an uncomplicated postoperative recovery•
Correspondence to: Dr D. C. F. Lloyd, Department of Diagnostic Radiology, University Hospital of Wales, Heath Park, Cardiff CF4 4XN.
Fig. 1 - The single film from the barium study shows a dilated stomach, with abnormal orientation of the duodenum giving the first coil of a corkscrew appearance. There is complete duodenal obstruction.
DISCUSSION I n t e s t i n a l o b s t r u c t i o n d u e to m i d g u t m a l r o t a t i o n u s u a l l y o c c u r s d u r i n g early c h i l d h o o d , 7 5 % o f cases o c c u r r i n g in t h e first m o n t h o f life [1]. P r e s e n t a t i o n in a d u l t h o o d is r a r e w i t h few r e p o r t s in t h e l i t e r a t u r e [2]. P e r i t o n e a l b a n d s c r o s s i n g the d u o d e n u m a r e a l m o s t a l w a y s p r e s e n t in cases o f o b s t r u c t i v e m a l r o t a t i o n . T h e s e b a n d s a l s o fix t h e p r o x i m a l p o r t i o n o f t h e t r a n s v e r s e c o l o n in the r i g h t u p p e r q u a d r a n t a n d the p o s i t i o n o f t h e c a e c u m c a n t h e r e f o r e b e n o r m a l , t h o u g h it is classically h i g h [3]. T h i s e x p l a i n s t h e r o u t i n e i n c i s i o n f o r a p p e n d i c e c t o m y in this case. The diagnosis can be made on upper gastrointestinal contrast examinations by demonstrating that the duod e n o - j e j u n a l flexure d o e s n o t lie in its e x p e c t e d p o s i t i o n in t h e left u p p e r q u a d r a n t o f t h e a b d o m e n [4]. T h e d i a g n o s i s is easily m i s s e d u n l e s s t h e f o u r t h p a r t o f t h e d u o d e n u m is e x a m i n e d w i t h this d i a g n o s i s in m i n d . I n this case a
SMALL BOWEL VOLVULUS DURING PREGNANCY
barium m e a l p e r f o r m e d during the neonatal period was said to have been normal. It has recently been d e m o n strated that diagnosis o f malrotation can be m a d e sonographically by demonstrating the superior mesenteric vein to lie anterior or to the left o f the superior mesenteric artery [5]. However, a barium study will usually be necessary to confirm that this has caused obstruction, and to identify the level o f obstruction. With the increasing use o f ultrasound to diagnose pyloric stenosis in vomiting babies, it is important to remember the possibility o f m a l r o t a t i o n and if possible note the relationship o f the superior mesenteric vessels. D u r i n g early pregnancy 50% of w o m e n complain o f nausea, and one third o f these vomit. H o w e v e r such s y m p t o m s usually settle towards the end o f the first trimester. In cases o f severe or persistent vomiting, particularly if this begins after the first trimester, it is important to exclude intestinal obstruction [6]. Intestinal obstruction in pregnancy is m o s t c o m m o n l y caused by adhesions, followed by volvulus, with small bowel volvulus accounting for just under 7% o f all cases [7]. Finding an increase in the incidence o f volvulus towards the end o f pregnancy, H a r e r and H a r e r [7] concluded that displacement o f bowel can precipitate obstruction and that the presence o f the gravid uterus might prevent spontaneous reduction. Unfortunately, t h o u g h they state that an underlying congenital abnormality was present in 25% o f patients with volvulus, the specific incidence of m a l r o t a t i o n is not mentioned. The N a t i o n a l Radiological Protection Board [8] estimates the probability o f induction o f a childhood cancer following an average barium meal performed during pregnancy (a dose to the pelvis o f 3.6 m G y ) to be approximately 1 in 4500. This compares to a natural incidence o f 1 in 1800 [9]. The risk can be reduced by
287
performing a limited examination, with careful attention to screening time, collimation o f the X - r a y beam, and a single radiograph using a cassette with rare earth screens to record any abnormality. Whenever possible, diagnostic radiation during pregnancy should be avoided [10]. W h e n radiological investigation is indicated, this should be performed promptly, with care to m i n i m i z e radiation dose to the fetus. Delay in the diagnosis o f volvulus can lead to ischaemic bowel, endangering the health and life o f m o t h e r and fetus [7].
REFERENCES
l Berdon WE, Baker DH, Bull S, Santulti TV. Midgut malrotation and volvulus. Which films are most helpful? Radiology 1970;96:375383. 2 Wang C, Welch C. Anomalies of intestinal rotation in adolescents and adults. Surgery 1963;54:839-855. 3 Girdany BR. The abdomen and gastrointestinal tract. In: Caffey's pediatric X-ray diagnosis', 8th ed. Chicago: Year Book Medical Publishers Inc., 1985:1481. 4 Alford BA, Keats TE. The gastrointestinal tract; The newborn and young infant. In: Grainger RG & Allison DJ, eds. Diagnostic radiology. Edinburgh: Churchill Livingstone, 1986:912-913. 5 Gaines PA, Saunders AJS, Drake D. Midgut malrotation diagnosed by ultrasound. Clinical Radiology 1987;38:51-53. 6 Hibbard BM. Gastrointestinal function and dysfunction. In: Principles of obstetrics. London: Butterworths, 1988:227 242. 7 Harer WB, Harer WB. Volvulus complicating pregnancy and puerperium. Obstetrics and Gynaceology 1958;12:399-406. 8 Patient dose reduction in diagnostic radiology. National Radiological Protection Board. London: HMSO, 1990. 9 Russell JGB. Diagnostic radiation, pregnancy and termination (letter). British Journal of Radiology 1989;62:92-94. 10 Exposure to ionising radiation of pregnant women; advice on the diagnostic exposure of those who are, or may be pregnant. National Radiological Protection Board. London: HMSO, 1985.
