Document Type : original article


1 Surgical Oncology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

2 School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran

3 MD, Faculty of Medicine, Islamic Azad University – Mashhad Branch, Mashhad, Iran

4 Radiology Department, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran


Background: Malrotation is an emergency, mainly in pediatric cases, and needs a timely and prompt diagnosis. Upper gastrointestinal (GI) contrast study used to be an acceptable modality in the diagnosis of malrotation; however, it has many disadvantages. In this regard, sonography has tried to take the place of upper GI studies. The aim of our study is to assess sonography and upper GI series as diagnostic methods for malrotation.
Methods: In a cross-sectional study, 154 pediatric cases suspected of malrotation were enrolled. The patients underwent upper GI series and sonography. In the case of sonography, two different findings, including inversion of the superior mesenteric vein (SMV) and superior mesenteric artery (SMA) and deviation (abnormal pathway) of the mesenteric artery were assessed. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of different sonography findings and upper GI study were calculated.
Result: Different sonography findings showed various diagnostic values. Inversion of SMV/SMA had a sensitivity of 58.87%, specificity of 36.17%, PPV of 67.74%, and NPV of 27.86%. Furthermore, the sensitivity, specificity, PPV, and NPV of deviation (abnormal pathway) of mesenteric vessels were 89.87%, 17.02%, 64.54%, and 50%, respectively. Taking into consideration the two findings together, sonography showed a sensitivity of 73.83% and PPV of 67.74%. Moreover, the sensitivity, specificity, PPV, and NPV of upper GI studies were 82.5%, 100%, 100%, and 50%, respectively.
Conclusion: Mesenteric vessel abnormalities may be valuable in detecting malrotation, but still upper GI contrast study is better. Development of other sonographic markers of malrotation, especially for different ages, is necessary.


  1. Anand U, Kumar R, Priyadarshi RN, Kumar B, Kumar S, Singh VP (2018) Comparative study of intestinal malrotation in infants, children, and adults in a tertiary care center in India. Indian Journal of Gastroenterology 37:545-549.
  2. Brandt ML, Singer J, Heyman M, Wiley J (2019) Intestinal malrotation in children. UpToDate, Feb 19.
  3. Williams OM, Olson JK, Kenney BD (2020) Intestinal Malrotation and Midgut Volvulus. Pediatric Surgery. Springer, pp 679-685.
  4. Chou S, Bertolli M (2017) Malrotation and midgut volvulus. Succeeding in Paediatric Surgery Examinations. CRC Press, pp 338-345.
  5. Dekonenko C, Sujka JA, Weaver K, Sharp SW, Gonzalez K, Peter SDS (2019) The identification and treatment of intestinal malrotation in older children. Pediatric surgery international 35:665-671.
  6. Nasir A, Abdur-Rahman L, Adeniran J (2011) Outcomes of surgical treatment of malrotation in children. African journal of pediatric surgery 8:8.
  7. Lee HC, Pickard SS, Sridhar S, Dutta S (2012) Intestinal malrotation and catastrophic volvulus in infancy. The Journal of emergency medicine 43:e49-e51.
  8. Alamdaran SA, Hashemi J, Layegh P, Taghavi M (2015). The diagnostic value of ultrasonography in pediatric intestinal malrotation. Growth 5:3-8.
  9. Tang V, Daneman A, Navarro OM, Gerstle JT (2013) Disorders of midgut rotation: making the correct diagnosis on UGI series in difficult cases. Pediatric radiology 43:1093-1102.
  10. Sizemore AW, Rabbani KZ, Ladd A, Applegate KE (2008) Diagnostic performance of the upper gastrointestinal series in the evaluation of children with clinically suspected malrotation. Pediatric radiology 38:518-528.
  11. Valentini V, Piccolo CL, Napoletano M, Mamone R, Zuccolini M, Miele V (2016) Intestinal Malrotation and Volvulus. Imaging Non-traumatic Abdominal Emergencies in Pediatric Patients. Springer, pp 31-43.
  12. Alehossein M, Abdi S, Pourgholami M, Naseri M, Salamati P (2012) Diagnostic accuracy of ultrasound in determining the cause of bilious vomiting in neonates. Iranian Journal of Radiology 9:190.
  13. Zhang W, Sun H, Luo F (2017). The efficiency of sonography in diagnosing volvulus in neonates with suspected intestinal malrotation. Medicine 96.
  14. Zhou L-y, Li S-r, Wang W, Shan Q-y, Pan F-s, Liu J-c, Xie X-y (2015) Usefulness of sonography in evaluating children suspected of malrotation: comparison with an upper gastrointestinal contrast study. Journal of Ultrasound in Medicine 34:1825-1832.
  15. Nehra D, Goldstein AM (2011) Intestinal malrotation: varied clinical presentation from infancy through adulthood. Surgery 149:386-393.
  16. Lampl B, Levin TL, Berdon WE, Cowles RA (2009) Malrotation and midgut volvulus: a historical review and current controversies in diagnosis and management. Pediatric radiology 39:359-366.
  17. Orzech N, Navarro OM, Langer JC (2006). Is ultrasonography a good screening test for intestinal malrotation? Journal of pediatric surgery 41:1005-1009.
  18. Strouse PJ (2004) Disorders of intestinal rotation and fixation (“malrotation”). Pediatric radiology 34:837-851.
  19. Taghavi M, Alamdaran SA, Feizi A (2018) Diagnostic value of ultrasound and gastrointestinal series findings in detection of pediatric intestinal malrotation. Iranian Journal of Radiology 15.
  20. Garcia AM, Asad I, Tessaro MO, Sivitz A, Osborn K, Shahinfar A, Leung SK, Rowe E, Riera A (2019) A multi-institutional case series with review of point-of-care ultrasound to diagnose malrotation and midgut volvulus in the pediatric emergency department. Pediatric emergency care 35:443-447.
  21. Epelman M (2006). The whirlpool sign. Radiology 240:910-911.
  22. Jarahi L, Mahmoudi R, Yazd MV, Ghodsi H, Ramezani M, Omranzadeh A (2021) Association of Sociodemographic, Obstetric, and Attitudinal Factors with Prenatal Ultrasound in Mashhad, Iran. Journal of Child Science 11:e222-e226.
  23. Alamdaran SA, Mahdavi Rashed M, Arjmand S, Rahimzadeh Oskooei R (2021) Mesenteric Vessel Abnormalities Detected With Sonography: A Possible Gateway to the Early Diagnosis of Various Gastrointestinal Anomalies. Journal of Diagnostic Medical Sonography 37:32-39.