PMC5960549_01
Ultrasound images of the key antenatal findings: (a) dilated appearing stomach with relatively normal duodenal diameter, not consistent with duodenal atresia; (b) concentric small bowel visible around the twisted mesenteric pedicle (whirlpool sign) and the superior mesenteric vein malpositioned on the left of the artery; and (c) dense sediment noted in the amniotic fluid, which was noted to be bile at the time of delivery.
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Initial ultrasound examination showed a moderately dilated fetal stomach, distended bowel loops, and aperistalsis (Figure 1). The coffee-bean and whirlpool signs were both evident; the latter is shown in Figures 1 and 2.
Ultrasound images showing progressive changes within the fetal bowel over time. (a) At 31+6 weeks, echolucent bowel contents with a diameter of 14 mm. (b) At 31+6 weeks, a loss of clear bowel wall border. (c) At 32 weeks, increasing echogenic particles within the bowel lumen. (d) At 32+1 weeks, bowel contents appear echogenic.
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Daily ultrasound surveillance showed persisting bowel dilatation up to 18 mm in diameter, with increasing echogenicity noted over time, with minimal peristalsis and loss of definition in the bowel wall, indicating oedema as shown in Figure 2. The coffee-bean and whirlpool signs were both evident; the latter is shown in Figures 1 and 2.
Radiographic images from day 1 and day 2 postnatally. (a) Contrast study performed on day 1 of life excluding malrotation and (b) large pneumoperitoneum evident on abdominal X-ray on day 2 of life.
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On day 1 of life, the baby remained well with no abdominal signs and a contrast swallow was performed, which did not show obvious malrotation (Figure 3(a)). An abdominal X-ray on day 2 showed a pneumoperitoneum (Figure 3(b)).
Clinical photos: (a) clinical appearance of infant on day 2 of life with erythematous, distended abdomen, and (b) in operating theatres ileal volvulus visible with a necrotic segment on the left side.
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An urgent laparotomy was then performed, with findings of an ileal volvulus with meconium peritonitis (Figure 4).