Apple peel small bowel. Imaging case book

Abstract

We have read with interest the article from Herman and Siegel related to imaging in the case of apple peel small bowel (APSB) or ‘Christmas tree deformity’. In the context of the diagnostic value of upper gastrointestinal series complemented by contrast enema for APSB, the authors described in detail the pathogenesis of this type of intestinal atresia. Although it is generally accepted that the majority of APSB cases result due to early in utero vascular accidents, APSB most likely represents a spectrum of disorders that includes hereditary phenotypes. However, the authors did not make mention of the pathogenetic role in APSB of intrauterine disruptive events such as volvulus, internal herniation and intussusceptions. In cases of jejuno-ileal atresia, such events are typically observed in single mid and low atresias. To demonstrate the pathogenetic role of late intrauterine events, we can add a unique case of APSB due to intrauterine midgut autoamputation caused by midgut volvulus. The baby was the first child of a 20-year-old mother with a history of ongoing heavy nicotine abuse. In the 26th week of gestation, small bowel obstruction due to volvulus was found by serial intrauterine ultrasounds. Owing to preterm labor, the baby was delivered by cesarean section in the 33rd week. Postnatally, the diagnosis of upper bowel obstruction was confirmed by ultrasound and plain X-ray. No air was seen distal to the proximal jejunum. At laparotomy, an apple peel-type jejunal atresia was noted 10 cm below the duodenojejunal flexure with largely dilated oral jejunum, mesenteric defect, concomitant volvulus of the distended oral jejunum and spiraled short segment terminal ileum with absence of the dorsal mesentery (Figure 1). Neither embryonic cords nor abnormal fixation of the narrow colon was observed. Surprisingly, a free-floating helical atretic bowel segment of browngreen color was found within the peritoneal fluid (Figure 2). Its intestinal origin was confirmed by histology, which revealed a