• Malrotation: Any abnormal rotation of small or large bowel, which rotate separately during development

  • Malfixation: Abnormal position or length of bowel fixation by mesentery, typically associated with malrotation

    • Short mesenteric fixation predisposes to midgut volvulus [twisting of midgut about superior mesenteric artery (SMA) → vascular occlusion & potential bowel ischemia]


  • Fluoroscopic GI findings

    • 3rd duodenum (D3) never crosses midline, often extends anteriorly on lateral view of upper GI

    • Duodenojejunal junction lies right of left pedicle & below duodenal bulb on true frontal view of upper GI

    • Variable degrees of colonic malrotation with abnormal cecal position on enema or small bowel follow-through

  • US/CT/MR

    • Duodenal nonrotation: D3 segment fails to pass between SMA & aorta when crossing to left of midline

    • Reversal of normal SMA/superior mesenteric vein position (not reliable)

  • Best imaging tool

    • Fluoroscopic upper GI vs. ultrasound debated


  • Typically isolated but common in congenital diaphragmatic hernia, gastroschisis, omphalocele, & heterotaxy

Clinical Issues

  • Majority present in infancy with nonbilious or bilious emesis, recurrent abdominal pain, or poor weight gain; may be asymptomatic

  • Treated with Ladd procedure: Untwist volvulus if present, divide Ladd bands if present, reposition small & large intestine into right & left abdomen, respectively

Anterior graphic shows abnormal positions of the small & large bowel. The duodenojejunal junction (DJJ) lies low & midline
, very close to the malpositioned cecum
. This results in a short mesenteric fixation that predisposes to midgut volvulus.

Lateral upper GI image in a 3-year-old child with a history of nonbilious vomiting shows an anterior, intraperitoneal course of the D3 segment with a low position of the DJJ
below the duodenal bulb
, indicating abnormal rotation.

Supine front view of the same patient shows a low DJJ
(below the duodenal bulb
) that fails to cross the midline, consistent with malrotation. Note that there is no twisting or dilation of the duodenum to suggest midgut volvulus or obstructing Ladd bands.

Supine SBFT was continued in the same patient to determine the cecal position & estimate the length of the mesenteric pedicle. The cecum (C) is high & just left of the midline, suggesting a very short mesenteric pedicle that is at high risk of future midgut volvulus.


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