Z-shaped duodenojejunal loop: sign of mesenteric fixation anomaly and congenital bands

Area of Science:

• Pediatric Gastroenterology
• Surgical Anatomy
• Congenital Malformations

Background:

• Intermittent abdominal pain and vomiting are common symptoms in children.
• Duodenal obstruction and malrotation are significant causes of these symptoms.
• The ligament of Treitz marks the junction of the duodenum and jejunum, a critical area for intestinal rotation.

Purpose of the Study:

• To describe the diagnostic utility of the Z sign in identifying incomplete intestinal rotation.
• To correlate the radiographic Z sign with intraoperative findings.
• To emphasize the significance of the Z sign even in the absence of complete duodenal obstruction.

Main Methods:

• Retrospective review of four pediatric cases (ages 3-9 years) presenting with intermittent abdominal pain and vomiting.
• Analysis of upper gastrointestinal (GI) examinations to identify the characteristic Z configuration of the distal duodenum and proximal jejunum.
• Correlation of radiographic findings with intraoperative observations, specifically the presence of peritoneal bands.

Main Results:

• Upper GI examinations revealed a distinct Z configuration (sharply angulated to-and-fro course) of the distal duodenum and proximal jejunum in all four children.
• Intraoperative findings confirmed the presence of broad peritoneal bands extending across the small intestine at this level.
• No accompanying volvulus was noted at the level of the Z sign, and duodenal obstruction was not a consistent feature.

Conclusions:

• The Z sign on upper GI studies is a reliable indicator of incomplete intestinal rotation in children.
• This radiographic finding is associated with peritoneal bands and can be diagnostic even without complete duodenal obstruction or apparent malposition of the proximal jejunum.
• The Z sign aids in the diagnosis of malrotation, guiding surgical intervention for pediatric abdominal pain.