Loading summary
Transcript9 lines
- [00:04]
A
When did making plans get this complicated? It's time to streamline with WhatsApp, the secure messaging app that brings the whole group together. Use polls to settle dinner plans. Send event invites and pin messages so no one forgets mom 60th and never miss a meme or milestone. All protected with end to end encryption. It's time for WhatsApp message privately with everyone. Learn more@WhatsApp.com podcast family let me just say it right now. Our topic for today, which comes from a real world application. We have a patient right now in our high risk clinic that has fetal dextrogastria. This is not common. It is rare. It is rare, but just because it's rare doesn't mean you don't have to know about it. Because one day you may see, doing a routine second trimester ultrasound, you're like, wait a minute, that stomach bubble looks kind of weird. It's present, but isn't it supposed to be on the other side? Remember, under normal conditions, usually and almost universally the fetal stomach bubble is seen on the left side of the fetal abdomen. But when it's seen on the right side, that's called fetal dextrogastria. We have a paucity of data. We don't have a lot of data here on this, but what we do have is very enlightening and, and we have a clear path here of what to do if we suspect that the fetal stomach bubble is on the wrong side. Now, just to be complete. We'll also add a little flavor here in this episode of what to do if you don't see a stomach bubble. That's a separate issue. Our patient did have one. It was just on the wrong side of the fetal abdomen. So we are going to touch on the absent stomach bubble just to be complete, but we're going to talk about fetal dextrogastria. This is a rare kind of malrotation of a congenital anomaly that happens in the abdomen. And, and it sometimes, even though we think it's isolated, we don't see anything else. That doesn't necessarily mean the baby's in the clear and still needs a complete post birth evaluation. It's weird. It's out there. I mean, it's like 1 in 10,000 according to the published literature. 1 in 10,000, but somebody's at 1. So we're going to talk about something that thankfully isn't very common, but we need to be aware of isolated or not so isolated, Fetal dextrogastria. I think I've set it up enough here we Go. You're listening to the obgyn no Spin podcast. So I like when we cover rare things because I always get messages back like, oh, I didn't know that was a thing. Yeah, I mean, I remember learning this a long time ago. And it's been, oh, my goodness, a good, what, 15 years that I've seen. It's been 15 years, guys, because I had one in Dallas. Here's another one. Now, remember the numbers here, like 1 in 10,000, but yet I've seen two. So either it's higher than we think, or, man, I see a lot of patients, and it's probably a combination of both. But, yeah, this is my second one over many years, but this is number two. So it is out there. You got to keep looking for it, because at its worst issue is that it carries other friends with it. That could be problematic because when you find isolated dextrogastria, that's kind of a loaded term because just because we don't see something on the fetal ultrasound, that's great. But. But sometimes you pick something up after delivery. And I'm going to give you that report from a case series here in just a minute. So just because you don't see something. Now, let me be very clear. That's very reassuring. That's great. But have a low index of suspicion for 3D ultrasound. Be very thorough in this anatomical scan, these level two ultrasounds, to make sure we're not missing anything else. Because for things like intestinal atresia, situs, inverses, other congenital cardiac defects, all of these things have been reported with dextrogastria. Okay, now, to be very clear, if that's the only thing you find, everything else looks totally normal on the ultrasound. Super reassuring, super good news. Doesn't necessarily mean we're out of the woods, because some of those things may present later. But it definitely is reassuring if nothing else is seen. That's for sure. But isn't this wild? This is. This is a rare issue, and it's not clear what causes this thing, but it seems to be something in the original rotation of the mid gut. So you got to go back to embryology. We're not going to get into it. But, but, but in the connection from the peritoneal connection, as the mid gut is rotating into position, rather than rotating exactly to the left, it kind of rotates and spins so that the stomach is on the right. That's abnormal. Now, it's potentially been linked to some genetic issues, but that's not really clear. What is clear is that there's definitely an association with other anomalies, so we got to keep looking for things. Now, if that's it, and that's really all the child has, outside of an increased likelihood later of GERD and maybe diaphragmatic hernia, isolated dextrogastria, thankfully, if that's all that it is, seems to be relatively benign. Again, GERD is one thing, but as long as that's all that's seen, as long as the heart isn't involved, the diaphragm doesn't have a hernia, there's no sinus inversus, then that seems to be okay. The issue is, again, you have to do a very thorough evaluation, including a postnatal echo, which some have called for, others have not. Okay, so the bigger issue that may potentially happen is not a congenital anomaly, but the later occurrence, possibly of intestinal malrotation. This all goes with this whole embryological deviation in how the stomach is placed. This is why, even though you're in the clear at delivery, you know the child may be set up later for other issues because he's got an organ located on the wrong side of the body. Now, this has also been linked to a variety of other things. Like we've already mentioned gerd, it's been linked to cardiac defects, that is inverses has been linked to asplenia. How about that? It's like, well, if the spleen says, hey, you're going to be over here, I'm not, I'm not coming. It's been linked to asplenia. At the same time it's been linked to polysplenia. That's multiple spleens. So it's weird. That's why even though there's no consensus here to be very conservative, some have suggested getting a fetal MRI to make sure nothing else is done. I think that's fine. I think a 3D ultrasound is, does a great job as well. But there's no universal call for fetal MRI unless you suspect multiple other issues. We'll touch on that just briefly once again, when we get to the workup in 2016. In 2016, in the journal Pediatric Surgery, authors published this retrospective review of 20 cases. Now, that's pretty impressive because this is pretty rare, but they found 20 cases, all of antenatally diagnosed dextrogastria. Okay. This spanned a 10 year interval from 2004 to 2014. So even though it's a small N, the results of what they found were pretty striking. Remember, this is a journal of Pediatric Surgery. Using AN N OF 20 now, of those, eight ended up being terminations. Now, it's unclear why that happened. I mean, isolated dextro gastria is not a lethal condition, but whatever. Eight were terminations. We're not gonna get into that. One was an intrauterine death, so that's nine. And then one child had no postnatal information available. So like, well, we don't know what happened to that one. So that's 10. So automatically we're left with 10 out of the 20 that they're going to report on. Okay, remember 2016? So almost 10 years ago. The Journal of Pediatric Surgery. This is, by the way, one of the biggest reviews out there because this is rare and you got to follow them. Of those 10 infants that were live born, two died. Guys. Two died secondary to cardiac disease in the neonatal interval. This is why guys don't take this lightly. Oh, hey, your stomach bubble is on the wrong side. He. He's kind of cute. No, it's not cute. It's not cute at all. It's a problem. Look for other organs. 2 out of 10 die due to cardiac issues and in the neonatal period. This is why, guys, you see, dextrogastria can do bad things. Now, these also had significant vascular anomalies when they were assessed after delivery. That's why, you know, some make that universal call, just get an echo. Even if they had a normal echo during the antepartum evaluation, prenatally do it after delivery. Now, I'm all for that. I think it's better to make sure nothing else is going on, especially with Doppler flow. Make sure that the gradients are fine, that nothing is being missed. So I'm a fan of doing echo, of course, both prenatally and after delivery.
- [09:24]
B
This episode is brought to you by Jack Daniels. Jack Daniels and music are made for each other. They share a rhythm in the craft of making something timeless while being a part of legendary nights. From backyard jams to sold out arenas, there's a song in every toast. Please drink responsibly. Responsibility.org, jack Daniels and Old no. 7 are registered trademarks. Tennessee whiskey, 40% alcohol by volume. Jack Daniel Distillery, Lynchburg, Tennessee.
- [09:49]
A
Limu game.
- [09:50]
B
Oh, and Doug, here we have the Limu emu in its natural habitat, helping people customize their car insurance and save hundreds with Liberty Mutual. Fascinating. It's accompanied by his natural ally, Doug.
- [10:07]
A
Limu is that guy with the binoculars watching us.
- [10:09]
B
Cut the camera. They see us. Only pay for what you need@liberty mutual.com. liberty.
- [10:14]
A
Liberty.
- [10:14]
B
Liberty. Liberty Savings. Very unwritten. By Liberty Mutual Insurance Company affiliates excludes Massachusetts.
- [10:20]
A
So of those that that had dextrogastria with a cardiac, a severe cardiac or vascular anomalies, two of those died. Two neonates developed bilious vomiting and underwent a procedure called LADS procedure lad not to get into that, we're not pediatric surgeons. But it is, it's a way to resolve a GI obstruction and do other things. So two neonates availabilius vomiting and underwent a LADS procedure. Now the operative findings were dextrogastria and malrotation in both of those. So it's not just at its position in the wrong way. As I've said a little while ago, it can actually twist on its axis. So even though nothing else is going on, it can still lead to this intestinal malrotations, almost like a volvulous issue and give problems. A third child had gastroesophageal reflux and contrast, demonstrated stable duodenal midgut position. This child, quote, has not been, had not yet developed symptoms attributable to malrotation and had not undergone surgery by the end of their chart review. End quote. Okay, so again, potentially there for some issues, but nothing there was worrisome. Now listen to this. Three of these infants had asplenia or polysplenia. So there you go. And of course if they have asplenia, then you have to give immunosuppression or antibiotic prophylaxis. You see, it's not. Well, and we just started out with it's just a stomach bubble on the wrong side. You gotta look at the heart, you gotta look at the entire chest, you gotta look at the spleen. Five children in this series were not investigated for malrotation and quote, had not come to surgical attention by the time of this chart review. Closure, end quote. So just again the question is, well, how long do you follow these? The answer is it seems to be for a while, including up to the teenage years, because they can be asymptomatic for a long time. In 2022, in the journal BMC Gastroenterology, authors published a case report of a 19 year old male who had this three month history of abdominal pain and, and two days of vomiting and constipation. Now isn't that just a typical dude, right? I mean, three months of abdominal pain, two days of puking and he can't go to the bathroom. Then he comes in for eval. That's just a guy thing. You're like, I think I better go get this. It's been like six Months. I'm really. It's really killing me now. But I digress. So there's more. So check this out. This case report states, quote, the patient had reduced air entry in the base of the right lung. A large air fluid level was found in the right lower hemithorax. Furthermore, a loss of the normal diaphragmatic outline and lack of bowel gas in the rest of the abdomen. End quote. Y' all get this, y'. All. There's something happening in the right side of the chest and the rest of the intestines look weird. You all see how this was 19 years old. Now, this relates to what we're talking about with gas with dextrogastria, because this is all related to this. Remember, totally asymptomatic until age of 19. They continue. Quote. Computer tomography with contrast was suggestive of loss of right lung volume with stomach and bowel loops herniating into the right hemithorax and compressive atelectric changes in the adjacent lung alongside an enlarged liver. End quote. Short of it is the diagnosis was isolated dextrogastria with eventration. So that's like evisceration, but eventration. That means something goes up of right hemidiaphragmatic and hiatal hernia. What? I mean, asymptomatic for 19 years. And that isolated dextrogastria was now invading the hemi diaphragm because of a hiatal hernia. Wow. So could this have been prevented? Maybe. I mean, if the people knew that this young adult, the child had this could have been screened maybe. And definitely would have been told not to wait three months for you to have severe abdominal pain. But it all goes to show that we can't take any weird finding on ultrasound. Guys, here's a clinical pearl. Act on it. I mean, do something about it. Some of those things are more benign. Mild renal pelvic dilation, pileectasis in a male infant, meltiness, potentially. You just track that could be fine. That's going to resolve. But things that are weird like this, if the stomach bubble is on the incorrect side, meaning on the right side rather than the the left, that's called dextrogastria. And don't ignore that. We're going to finish this up real quickly, guys, because this is a relatively fast. And this is just call to attention to this weird thing. I told my resident. I think I'm gonna. We should talk about this on the podcast because it's pretty weird for workup. Super easy. Pay attention to 2D ultrasound. If you have any question, then get a 3D ultrasound. But the standard evaluation, of course, is regular old 2D ultrasound. 3D ultrasound does have a role here that's been published as has fetal MRI like we talked about. And having a wrong side stomach bubble is one thing. If you don't see a stomach bubble, that's a whole other issue. An absent fetal stomach on ultrasound. And we're just saying this to be complete. Our patient did have a stomach bubble and. But if you don't see anything at all, then you got to keep looking for it to make sure that you're in the right plane. But that could be either a physiological issue or a pathological issue. Physiological is maybe the stomach emptied and you caught it at a weird contraction point and nothing is in there. You got to wait a little bit. And that's the main part of the physiology. But there are a lot, a long list of pathological causes from neuromuscular issues that prevent the child from swallowing. It could be an anatomical issue where the mouth prevents taking fluid in like micrognathia. It could be an amniotic fluid issue. It could be a diaphragmatic hernia. It could be other facial defects. A severe cleft lip could affect swallowing. So you've got to do a due assessment if you do not see a stomach bubble. So remember, stomach bubble, guys, we got three buckets, basically, right. Number one, is it on the right side? And I mean right as incorrect. Damn, that could have been confusing. Is it on the correct side, which is the left? If it's on the right side, that's called dextrogastria. That's wrong. So the first bucket is, what side is it at? Next bucket is, does it look normal or is it there at all? And then the last bucket is, is it a double bubble sign, which is its own separate issue that typically has to do with an obstruction like duatnal atresia, which is a more serious finding. All right, so don't just see a stomach bubble. See, make sure it's on the correct side. Make sure that it looks normal. And that is not a double bubble sign. So anyway, this is relatively quick. The short answer is, I like what the authors of the of a case report stated where they followed the, you know, those 10 infants because their conclusion was pretty spot on. They're like, look, sometimes this issue of dextrogastria isn't by itself. Consider a postnatal echo. Take a look at the spleen and remember that if they're otherwise asymptomatic from a GI standpoint, there's really nothing to do. You don't have to go investigate. Go digging around for mal rotation. They will present, but if they do have any signs of bilious vomiting or abdominal pain, consider an intestinal malrotation in patients who have the stomach bubble on the incorrect side being the right side. So, podcast family, this was relatively quick. Just wanted to give a quick word of awareness for fetal dextrogastria. And if it sounds like I'm rushing a little bit, I kind of am. Let me just tell you what what's going on. It's the first of October and it's close to 6pm central time. My time in in about 40 minutes, I promise to talk to a student group, which I do every year at our university. And so I got to get ready to do that. So anyway, fetal dextrogastria. Weird. And just because you haven't heard of it doesn't mean it doesn't exist. It is out there. Podcast family, as always, we're thankful for you. We're glad you're part of our podcast community. I got to get ready to go talk to this student org and now that I've done all that, let's take it home. Podcast family, we're thankful for all of the support that you've given us throughout the years. This has been the OBGYN no Spin podcast. We'll see you on the next episode. Sam.