Neonatal Vomiting

malrotation

I agree, i think it's malrotation too. Green vomit usually has bile in it, and is caused by an obstruction.

The correct answer

The correct answer is A, Ischemia
The picture is showing typical "Apple Peel" appearance of an ischemic segment of the small intestine.
Small bowel atresia is another cause of billious vomiting and it's caused by cut of arterial supply to a segment of the small intestine that renders the bowel loops to spiral up just like what's seen in the image "Apple Peel".
Intestinal atresia is a high yield topic that is frequently tested in USMLE Step 1 and Step 2.

wow thanx, i wouldn't have guessed that.

Malrotation is the answer. Because in this pic we can see both malrotation and ischemia both. But the question is that what is the cause? and the cause is malrotation.

shininggirl said:

Malrotation is the answer. Because in this pic we can see both malrotation and ischemia both. But the question is that what is the cause? and the cause is malrotation.

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How do you know it's malrotation from the picture?

Actually I came across a question like this in USMLE world, and they said that the apple peel appearance is characteristic of ischemia NOT malrotation.

is this a Step 1 question

Just wondering, is this a Step 1 like questions?

DrLANC said:

Just wondering, is this a Step 1 like questions?

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yeh, it could be. As it tests your embryology knowledge. But I'd say it's extremely uncommon.
Such a question is more likely a CK pediatric question.

YoramFishke said:

How do you know it's malrotation from the picture?

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Ischemia and malrotation both are seen in the picture. see how small intestine is tightly rotated on itself. this is not normal. it is malrotation (volvolus) causing ischemia.

shininggirl said:

Ischemia and malrotation both are seen in the picture. see how small intestine is tightly rotated on itself. this is not normal. it is malrotation (volvolus) causing ischemia.

Click to expand...

When malrotation has caused ishemia to the extent that the bowel was resected then it's usually gangrenous black bowels not like what you see in the image.
malrotation in neonates (unlike volvulus in adults) does not cause intestinal ischemia.

I disagree, I still believe this is malrotation, the white big arrow points to Ladd's bands, which are fixatiing the caecum to the non visible duodenum. What makes it difficult to see is that the ischemic small intestine is missed up.

Malrotation may present with duodenal obstruction due to bands and adhesions, or the small intestine will twist around the SMA causing a far more extensive ischemia than volvulous in old age.

I have come across jejunal atresia, and I have to say, I take back what I said.. This is definitely a type of jujunal atresia due to a vascular accident in utero.. As Sara said, this is called apple peel appearance (or Christmas tree apearance) because the small intestine wraps around the SMA and gives the appearance, it also causes the absence of dorsal mesentry at that area..

Ironically, it's associated with malrotation in some cases, I think this is one of them...