1Department of Radiology, Edirne Sultan 1. Murat State Hospital, Edirne, Turkey; 2Department of Pediatric Radiology Faculty of Medicine, Erciyes University, Kayseri, Turkey *Corresponding Author e-mail: msaitdogan@hotmail.com القولون اإلثين عشر املنقلب نتائج من صور متتالية للجهاز اهلضمي العلوي مهمت دوغان، �صليم دوغاناي، جونكا كوك، �صوريا جوركم، عبداحلكيم كو�صكون Duodenum Inversum Findings from an upper gastrointestinal series *Mehmet S. Dogan,1 Selim Doganay,2 Gonca Koc,2 Sureyya B. Gorkem,2 Abdulhakim Coskun2 interesting medical image A 12-year-old girl with a history of occasional nausea and vomiting for the previous 4‒5 years was admitted to the Erciyes University Children’s Hospital, Kayseri, Turkey, in 2014 after the frequency of these symptoms had increased. For the previous six weeks, she had been vomiting 6‒7 times per day and had lost 3 kg in weight. The laboratory findings and a physical examination were unremarkable except for non-specific epigastric tenderness. An upper gastrointestinal series (UGIS) was performed using a fluoroscopy device and barium contrast medium; this revealed that the third part of the duodenum was vertically oriented and subsequently crossed the midline to the left to form the duodenojejunal junction in the normal location, at the level of the bulb [Figure 1]. Based on these findings, a diagnosis of duodenum inversum was made. In addition, gastroesophageal reflux was observed. An endoscopic biopsy revealed peptic oeso- phagitis and chronic gastritis. There was no evidence Sultan Qaboos University Med J, August 2016, Vol. 16, Iss. 3, pp. e379–380, Epub. 19 Aug 16 Submitted 17 Feb 16 Revision Req. 21 Mar 16; Revision Recd. 29 Mar 16 Accepted 14 Apr 16 doi: 10.18295/squmj.2016.16.03.022 Figure 1A–F: Sequential images from an upper gastrointestinal series of a 12-year-old girl showing the (A) normal appearance of the first and second parts of the duodenum and the (B) third part of the duodenum bending over the second part and (C) continuing with a vertical orientation. Subsequently, the (D) duodenum crosses the midline to the left and the (E) duodenojejunal junction is located normally at the level of the bulb. Finally, the (F) proximal jejunal intestines are located in the left upper quadrant. The arrows show the route of the barium contrast medium. Duodenum Inversum Findings from an upper gastrointestinal series e380 | SQU Medical Journal, August 2016, Volume 16, Issue 3 predispose patients to diseases such as cholecystitis, pancreatitis and peptic ulcers.1–6 These symptoms and comorbidities are thought to be due to stasis in the duodenum.6 Clinicians must therefore be aware of possible comorbidities in patients with duodenum inversum. For symptomatic patients with peptic ulcers and without duodenal obstruction, pharmacological treat- ments are advised, including antacids, antispasmodics and anti-ulcer agents; however, if a duodenal obstruction is present, surgery is the treatment of choice.1 Although limited in number, studies have shown favourable outcomes for both surgical and pharmacological interventions.1,3,4 References 1. Kim ME, Fallon SC, Bisset GS, Mazziotti MV, Brandt ML. Duodenum inversum: A report and review of the literature. J Pediatr Surg 2013; 48:e47–9. doi: 10.1016/j.jpedsurg.2012. 10.066. 2. Fallon M. Duodenum inversum. Ir J Med Sci 1940; 15:256–60. doi: 10.1007/bf02952945. 3. Long FR, Mutabagani KH, Caniano DA, Dumont RC. Duodenum inversum mimicking mesenteric artery syndrome. Pediatr Radiol 1999; 29:602–04. doi: 10.1007/s002470050658. 4. Menchise AN, Mezoff EA, Lin TK, Saaed SA, Towbin AJ, White CM, et al. Medical management of duodenum inversum presenting with partial proximal intestinal obstruction in a pediatric patient. J Pediatr Gastroenterol Nutr 2016; 62:e64–5. doi: 10.1097/mpg.0000000000000519. 5. Childress MH. Duodenum inversum. J Natl Med Assoc 1979; 71:515–16. 6. Rozek EC, Graney CM. Duodenum inversum: A report of two cases. Radiology 1951; 57:66–9. doi: 10.1148/57.1.66. of duodenal obstruction, only duodenum inversum as seen during the UGIS. The patient was therefore prescribed 20 mg of oral omeprazole daily. Her symp- toms gradually resolved and she was noted to have gained 4 kg at a three-month follow-up evaluation. Comment Duodenum inversum, also known as inverted duodenum or duodenum reflexum, is a rare congenital anomaly of duodenal configuration which results in the third part of the duodenum bending over onto the second part posteriorly and crossing the midline at a more cephalic level than expected, subsequently forming the duodenojejunal junction at its original site.1–6 In an UGIS, radiological signs of duodenum inversum following the introduction of a contrast substance are as follows: (1) return of the contrast substance from the second into the first part of the duodenum and then into the bulb more frequently; (2) stasis in the duodenum; and (3) rapid passage of the contrast medium through the third stage.2 While the aetiology of duodenum inversum is unknown, it is believed to be due to the persistence of the dorsal mesentery with a mobile duodenum.5 Determining the normal location of the duodeno- jejunal junction is important in differentiating duo- denum inversum from intestinal malrotation.1–3 Patients with duodenum inversum are often asympto- matic, although they may present with obstructive symptoms, epigastric pain, bloating, nausea and vomiting. Furthermore, duodenum inversum may http://dx.doi.org/10.1016/j.jpedsurg.2012.10.066 http://dx.doi.org/10.1016/j.jpedsurg.2012.10.066 http://dx.doi.org/10.1007/bf02952945 http://dx.doi.org/10.1007/s002470050658 http://dx.doi.org/10.1097/mpg.0000000000000519 http://dx.doi.org/10.1148/57.1.66