Malrotation - Volvulus - Meconium Ileus - Solid Organ Injury: Update Course 2015
With Dr. Ken Azarow · hosted by Dr. Todd Ponsky · StayCurrentMD
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
In heterotaxy syndrome with right atrial isomerism, there is a higher incidence of malrotation compared to left atrial isomerism.
Appendectomy carries a slight long-term complication rate from adhesions.
A low-lying ligament of Treitz defines malrotation, not simply the duodenum crossing midline, because a floppy duodenum can cross midline without malrotation.
Many radiologists have switched from gastrografin to isotonic contrast (such as iohexol) for meconium ileus enemas, which defeats the therapeutic purpose of the enema.
Radiologists avoid gastrografin due to concerns about the hypertonicity of the contrast medium.
If a thorough enema has been performed with maximal pressure from below, it is not wrong to proceed with laparoscopy or laparotomy, because perforation in meconium ileus complicates things tremendously.
Current trend in solid organ injury management is to manage based on hemodynamics rather than CT grade.
Managing solid organ injuries based on hemodynamics allows patients to be discharged from the hospital much quicker than traditional protocols.
Tachycardia in solid organ injury patients may be due to pain, overlying broken ribs, or blood in the abdomen, requiring pain control to properly assess hemodynamic stability.
Patients with low-grade solid organ injuries and normal vital signs without tachycardia can be discharged in less than 24 hours.
A patient with grade 5 splenic injury can be discharged within 48 hours if hemodynamically stable and local to the hospital.
Activity restrictions after solid organ injury follow the grade plus 2 weeks rule (e.g., grade 3 injury = 5 weeks restriction).
Once a stable clot forms after solid organ injury (approximately 3 weeks), it is probably more stable than the remaining spleen.
In adults, 2 centimeters is the cutoff size for mesenteric vessel pseudoaneurysms at which intervention is typically considered.
In a Texas Children's series of 95 consecutive heterotaxy patients with malrotation, three-quarters underwent Ladd's procedure with no post-operative volvulus but 11% developed small bowel obstruction requiring admission and often surgery.
In the same Texas Children's series, 25% of heterotaxy patients were observed without surgery and had no small bowel obstruction or volvulus during 10-15 year follow-up.
Current literature shows overall success rates for meconium ileus enema reduction are declining on first attempts.
To achieve success rates above 60-75% for meconium ileus reduction, multiple enemas are required.
63% of successful meconium ileus enemas require more than one attempt in radiology.
Using hypertonic gastrografin on second or third enema attempts has been the contrast of choice for meconium ileus.
Literature is fairly clear that solid organ injury patients do not need to be reimaged after initial treatment.