Beyond the AP View: The Diagnostic Value of Lateral Duodenal and Colonic Assessment in Pediatric Malrotation

This study aimed to assess if the position of the duodenal-jejunal junction in the anteroposterior view can reliably diagnose malrotation and if atypical position of the duodenal-jejunal junction (medial to the left pedicle to midline) is associated with a low risk of narrow mesenteric root.Children diagnosed with intestinal rotational abnormalities (2007-2023) through upper gastrointestinal fluoroscopy (UGI) studies who underwent surgery were reviewed independently by two pediatric radiologists. Key observations included the duodenal-jejunal junction location in the anteroposterior view, duodenal position in the lateral view, jejunal loop position, and colon anatomy.Radiologists independently reviewed the UGI studies and disagreements between radiologists were resolved by consensus readings. Chi-square tests were used to compare the anatomical variables and the presence of surgically confirmed narrow mesenteric roots.Of the examined 79 children (mean age, 2 years), 60 (75.9%) underwent Ladd's procedure after confirming a narrow mesenteric root.According to the consensus, 77.1% of children with atypical duodenal-jejunal junction in the anteroposterior view had narrow mesenteric roots, and one had midgut volvulus. The likelihood of missing a surgically confirmed narrow mesenteric root was significantly lower (p = 0.0167) when considering the position of the duodenum in the lateral view, along with the jejunal loops and colonic position (0/3), compared with relying solely on duodenal-jejunal junction position in the anteroposterior view (29/37).The anteroposterior view alone is insufficient for diagnosing malrotation. Reviewing the lateral view of the duodenum, and when necessary, the colonic anatomy, reduces the risk of missing cases with surgically confirmed narrow mesenteric roots.