Collection
Acute Abdominal Conditions
Educational content from recorded physician discussions — not medical advice. Always talk to your child's care team about your child's situation.
Content of this collection
Diagnosis & Imaging2 items
Use and accuracy of diagnostic imaging in the evaluation of pediatric appendicitis.
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There are safety concerns about the use of radiation-based imaging (computed tomography [CT]) to diagnose appendicitis in children. Factors associated with CT use remain to be determined. For patients ≤18 years old undergoing appendectomy,
article · Nov 2026
Implementation of a Program for Appendicitis MRI in a Pediatric Hospital
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MRI is increasingly used as an alternate to CT for the evaluation of suspected appendicitis in pediatric patients presenting to the emergency department (ED) with abdominal pain, when further imaging is needed after an initial ultrasound ex
article · Nov 2026
Management Updates2 items
Update Course Rewind: Management of Appendicitis 2022
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Appendicitis is one of the most common conditions seen by pediatric surgeons but still has many controversies in management.
This topic was discussed in the 10th annual Update Course in Pediatric Surgery 2022, with Drs. Meera Kotagal, To
video · May 2023
Update Course 2022 - UPDATES IN APPENDICITIS MANAGEMENT - Meera Kotagal, Tolu Oyetunji, Shawn St. Peter, and Whit Holcomb
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Appendicitis is one of the most common conditions seen by pediatric surgeons but still has many controversies in management. With Drs. Meera Kotagal, Tolu Oyetunji, Shawn St. Peter, and Whit Holcomb we discuss the updates about treatment an
video · Sep 2022
If air enema successfully reduces the intussusception, patients are observed in the ED for four hours, then have a PO trial and can be discharged if clinically well. — Meera Kotagal, Intussusception Guideline · 4:30
Intussusception Guideline
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Dr. Meera Kotagal joins us again to discuss evaluation and management of patients with suspected intussusception, involving use of air enema, timing of surgical consult and role of early discharge after reduction.
video · Jul 2019
Impact of coronavirus disease 2019 on pediatric intestinal intussusception in the United States
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Background: Masking and social distancing to mitigate the spread of the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) virus curbed the spread of other viruses. Given a potential link between viral illnesses and ileocolic intu
article · Nov 2026
Serial abdominal exams every four hours are required throughout the protocol to ensure the patient has not progressed to peritonitis or developed an indication for urgent operative intervention. — Meera Kotagal, Gastrografin Protocol for Adhesive Small Bowel Obstruction (SBO) · 5:00
Malrotation1 item
Malrotation with Dr. Meera Kotagal
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In this podcast, we cover the basics of malrotation including embryology, presentation, differentiation, diagnosis, surgical approach, and post operative management with Dr. Meera Kotagal.
Host: Em Tombash
Animations to understand the
podcast13:25 · May 2023
Adhesive SBO1 item
Gastrografin Protocol for Adhesive Small Bowel Obstruction (SBO)
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Dr. Meera Kotagal discusses the use of gastrografin for diagnosis and potential therapeutic treatment for adhesive small bowel obstruction. Here you will find the evidence-based guideline in place at Cincinnati Children's Hospital (August 2
video · Sep 2019
After sclerotherapy, at least 3 months should elapse before considering surgery to allow the inflammatory reaction to subside — Meera Kotagal, Mesenteric and Omental Cysts · 9:00
Mesenteric and Omental Cysts
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Dr. Meera Kotagal, Pediatric Surgeon at Cincinnati Children’s, joins Dr. Rae Hanke to review the basics of mesenteric and omental cysts in this videocast.
video · May 2020
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Malrotation with Dr. Meera Kotagal
Malrotation occurs in about 1 in 200 to 500 live births.
Host summaryEm Tombash summarizes what Dr. Meera Kotagal said — not the host's own clinical position0:28 ↗
In the fourth week of gestation, bowel development begins, and as the bowel grows in length it herniates into the yolk sac along the umbilical cord and SMA axis.
clinicalMeera Kotagal1:17 ↗
Normal rotation involves a 90-degree rotation of the duodenal-jejunal loop, then return of bowel with 270-degree rotation of cecum and colon, resulting in duodenal-jejunal junction to the left of midline at ligament of Treitz and cecum in right lower quadrant.
clinicalMeera Kotagal1:44 ↗
Intestinal rotation abnormalities fall along a spectrum rather than being simply normal or abnormal, including both non-rotation and malrotation.
clinicalMeera Kotagal2:22 ↗
In non-rotation, the gut returns without rotating, resulting in colon on the left and small bowel on the right, without the problematic Ladd bands that cause obstruction in malrotation.
clinicalMeera Kotagal2:22 ↗
Non-rotation anatomy looks similar to the anatomy of a malrotated patient post-Ladd procedure.
clinicalMeera Kotagal2:22 ↗
Malrotation involves incomplete rotation that fails to create a broad-based mesentery, which is important to reduce the risk of volvulus.
clinicalMeera Kotagal2:22 ↗
Complications of malrotation fall into two categories: obstructive symptoms (feeding intolerance from Ladd bands) and midgut volvulus (from narrow mesentery).
clinicalMeera Kotagal3:49 ↗
About 1 in 200 children have a risk of malrotation, but only about 1 in 30 of those children with malrotation will develop a volvulus.
epidemiologicalMeera Kotagal3:49 ↗
About 70% of those who will have a midgut volvulus will present in the first year of life.
epidemiologicalMeera Kotagal3:49 ↗
As children with malrotation get older without having had a volvulus, their likelihood of having a significant clinical event related to malrotation decreases.
clinicalMeera Kotagal3:49 ↗
Children with congenital cardiac disease and heterotaxy especially can have associated malrotation, but their likelihood of symptomatic events is much lower, so these children are not fixed with the same frequency in infancy.
clinicalMeera Kotagal3:49 ↗
Rotational abnormalities are associated with congenital diaphragmatic hernia, gastroschisis, and omphalocele due to the nature of the anatomy of those diagnoses.
clinicalMeera Kotagal3:49 ↗
In the neonatal period, bilious emesis is the most critical symptom and requires evaluation for midgut volvulus even if the x-ray appears normal.
clinicalMeera Kotagal4:49 ↗
Other symptoms of malrotation include feeding intolerance, abdominal pain, and abdominal distension.
clinicalMeera Kotagal4:49 ↗
Late signs associated with volvulus include bloody stools, peritoneal signs on exam, and abdominal wall erythema, which are suggestive of intestinal ischemia.
clinicalMeera Kotagal4:49 ↗
The differential diagnosis for bilious emesis includes all kinds of intestinal obstructions: atresia, Hirschsprung disease, meconium ileus or plugs, incarcerated hernia, anorectal malformations, and necrotizing enterocolitis.
clinicalMeera Kotagal4:49 ↗
Malrotation must be ruled out before pursuing other diagnoses in a child with bilious emesis because of the high risk of missing it.
clinicalMeera Kotagal4:49 ↗
Upper GI series is the most frequently used imaging for diagnosis of malrotation, looking at the position and course of the duodenum to determine if it is normally or abnormally positioned.
clinicalMeera Kotagal4:49 ↗
On upper GI, you want to see the total C-loop of the duodenum come back across the midline to the left, and from lateral view see it go posteriorly and cephalad to confirm normal position.
clinicalMeera Kotagal4:49 ↗
Contrast enema can sometimes be used if cecal position can be determined, but current sensitivity and specificity are not sufficient to rule out significant pathology, so it has not superseded upper GI as the definitive test.
clinicalMeera Kotagal4:49 ↗
Midgut volvulus is considered the number one surgical emergency in pediatric surgery.
opinionMeera Kotagal4:49 ↗
Surgical treatment of volvulus requires exploratory laparotomy with evisceration of bowel to determine the situation, then detorsion/devolvulization of the bowel, usually requiring 270-degree counterclockwise rotation.
clinicalMeera Kotagal4:49 ↗
After detorsion, the bowel is given time to rest to assess viability and determine if ischemia has been prolonged enough to compromise intestinal viability.
clinicalMeera Kotagal4:49 ↗
You can have malrotation without midgut volvulus, but you cannot have midgut volvulus without malrotation.
Host summaryEm Tombash summarizes what Dr. Meera Kotagal said — not the host's own clinical position8:33 ↗
The Ladd procedure involves widening the mesentery by removing Ladd bands, freeing and straightening the duodenum to avoid obstruction, performing appendectomy, and placing bowel in non-rotation configuration (small bowel right, large bowel left) to keep mesentery as broad as possible.
clinicalMeera Kotagal8:54 ↗
The reason for appendectomy during Ladd procedure is that the appendix will be in an abnormal anatomic position, and if left in place, families must be informed to tell providers about the abnormal location if the child presents with concerning symptoms.
clinicalMeera Kotagal8:54 ↗
Some believe part of the benefit of Ladd procedure is widening the mesentery plus causing scar tissue that helps bowel adhere in a configuration preventing midgut volvulus.
opinionMeera Kotagal10:01 ↗
Laparoscopic Ladd procedure may have decreased adhesion rates, potentially losing the adhesive benefit that prevents volvulus.
opinionMeera Kotagal10:01 ↗
About one quarter of patients who undergo Ladd procedure will have intestinal obstruction related to small bowel obstruction from adhesive disease.
epidemiologicalMeera Kotagal10:01 ↗
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