In smaller hospitals, choosing between ultrasound or upper GI for suspected malrotation can feel high-stakes. During the latest AJR Live Webinar, Jonathan Dillman, MD, and HayThuy Nguyen, MD, tackled a key question:
Should community hospitals perform both ultrasound and upper GI—or is one enough before transferring a child?
The Big Picture
Even though ultrasound for midgut volvulus performs incredibly well in published studies, your institutional comfort and consistency matter. Smaller centers may see fewer neonates, and that affects how confident technologists and radiologists feel with real-time sonographic anatomy.
Dr. Nguyen’s advice: Start with both. Build confidence. Then taper.
Key Takeaways
Ultrasound + Upper GI Can Be Complementary, At First
- Even at large centers, both exams are often paired early on.
- Not because ultrasound underperforms, but because every institution needs their own “local data.”
- Once your team demonstrates consistently accurate ultrasound performance, you can safely drop routine upper GI.
See a Whirlpool Sign? Call Surgery!
A positive whirlpool sign on ultrasound is highly specific. No need to wait for additional imaging; direct referral to pediatric surgery is appropriate.
No Whirlpool, but Symptoms Persist → Consider Upper GI or Transfer
Ultrasound may still be equivocal in some infants. Upper GI remains a helpful confirmatory test when the diagnosis is uncertain but suspicion stays high.
Don’t Forget: CT or MRI Can Make the Diagnosis for Older Kids
Dr. Dillman emphasized that adolescents or older children being scanned for unrelated reasons may still show:
- SMV/SMA reversal
- Swirling mesentery
- Engorged mesenteric vessels
- Collaterals
Even a noncontrast CT for renal stone can incidentally reveal the vascular swirl. MRI—especially rapid MR protocols—can also depict abnormal vascular orientation.
Bottom Line
Start with both ultrasound and upper GI, if your institution needs to build confidence. Once your team demonstrates reliable ultrasound performance, ultrasound alone is often sufficient…and a positive whirlpool sign should trigger immediate surgical evaluation.
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