This is the case of a 2 year old female who presents with abdominal pain and bilious emesis. Due to the bilious emesis, the patient underwent an upper GI fluoroscopic image. This image demonstrates a dilated stomach and duodenum with a beak like appearance of the duodenum. This is due to a focal twisiting of the intestine due to congenital malrotation of the bowel as well as laxity of the mesenteric attachment. As can be seen on these images, the entirety of the visualized small bowel is to the left of the spine, which is an abnormal position. The dreaded complication of malrotation is volvulus. These patients need emergent surgery as twisting of the bowel can obstruct the venous outflow and arterial inflow to the intestine leading to bowel ischemia. The viability of the bowel will be assessed in the operating room and bowel resection will be performed if needed. PF224

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