5 day old boy presenting with bilious vomiting

AXR shows a markedly dilated gas filled stomach.  Note the presence of gas-filled bowel loops distally, which are not dilated.

Water-soluble contrast meal demonstrates a markedly dilated stomach.  Abnormal “cork-screw” configuration of the opacified duodenal and proximal jejunal loops is seen, which are located entirely to the right of the spine. 

This case is an “Aunt Minnie”, though diagnostic considerations for a neonate with evidence of upper gastrointestinal obstruction may include that of midgut malrotation, duodenal atresia / stenosis / webs or annular pancreas.

Midgut malrotation with volvulus

Water soluble contrast meal is the investigation of choice to investigate a neonate presenting with upper gastro-intestinal obstruction, allowing delineation of the anatomical configuration of the duodenum and proximal small bowel loops, as well as real-time appreciation of gastric emptying.  Of particular importance is the need to try to demonstrate the position of the duodeno-jejunal junction, which normally would be located to the left of the spine, at the same cranio-caudal level as the duodenal bulb.  The diagnosis of midgut malrotation represents a wide spectrum, ranging from completely asymptomatic individuals, to midgut malrotation with volvulus which represents a surgical emergency.  The “cork-screw” configuration of the opacified duodenal and proximal jejunal loops in this case, are pathognomonic for the latter.