Midgut volvulus is an extremely rare anomaly in adults. It can be an incidental finding or present with mild symptoms, but it can also lead to an intestinal obstruction or acute ischemia due to a midgut torsion requiring emergency surgery 1. It happens when your babys intestinal tract doesnt form as it should during pregnancy. Intestinal malrotation radiology reference article. Although 62% presented as neonates, 20% were over 1 year of age. Malrotation occurs when the intestine does not make the turns as it should. Intestinal malrotation and midgut volvulus johanna r. Intestinal malrotation develops as a result of a deficient rotation and fixation of the midgut segment after its passage through the umbilicus and return to coelomic space. A nine year experience in neonates article pdf available in annals of the royal college of surgeons of england 654. Neonatal malrotation with midgut volvulus mimicking. Operative reduction of the midgut volvulus and the gastric volvulus and repair of the gastric perforation was accomplished. Midgut volvulus in an infant with intestinal malrotation. Because of its rarity, the diagnosis of intestinal.
Intestinal malrotation with midgut volvulus presenting as. It occurs during the first trimester as the fetal gut undergoes a complex series of growth and development. Embryology, signs and symptoms, diagnosis and treatment for. Malposition of the intestine malposition malrotation volvulus midgut volvulus. Intestinal malrotation presenting with midgut volvulus in. Midgut volvulus occurs in people usually babies that are predisposed because of congenital intestinal malrotation. In conclusion, we present a rare case of malrotation with midgut volvulus in an adult.
Aiken malrotation is a term used to describe a spectrum of anatomic abnormalities resulting from incomplete rotation and fixation of the intestine during early fetal development. We present a case of bowel malrotation complicated by midgut volvulus in an adult patient. Primary midgut volvulus in a patient with marfan syndrome. Intestinal rotation abnormalities and midgut volvulus. Intestinal malrotation develops as a result of the intestines not being able to develop in. However, as the use of ct in emergency departments increases, midgut volvulus is increasingly being recognized in adults. Chapter 65 intestinal malrotation and midgut volvulus. Intestinal malrotation and volvulus in children what is intestinal malrotation in children. Intestinal malrotation is most commenly complicated by volvulus in the first weeks of life. Midgut volvulus is a lifethreatening complication of intestinal malrotation that should be diagnosed early and. Intestinal malrotation and midgut volvulus oxford medicine.
They all presented with features of intestinal obstruction. It can give clue about abnormal position of sma and smv. The midgut volvulus was then identified and approximated to be around 1. The opinions and assertions contained herein are the private views of the authors and are not to be constructed as official or as reflecting the views of the department of the navy or the department of defense. Pdf thirty four neonates presented with acute duodenal obstruction due to malrotation during a 9 year period between 1973 and the end of 1981. Midgut volvulus is a complication of malrotated bowel. By this method, the midgut volvulus is corrected by rotating the small intestine in anticlockwise manner with the cecum located on the left of abdomen and the duodenum down the right paravertebral gutter. Malrotation is in itself harmless, and an infant can have malrotation without a volvulus. Seven adults with midgut volvulus as a complication of malrotation are presented. As noted by ladd in 1932, malrotation is a condition rare enough that it is likely to escape the mind, and it is common enough to be important. Malrotation american pediatric surgical association. Kenney introduction malrotation is a spectrum of anatomic abnormalities of incomplete.
With these sonographic and radiographic features, the diagnosis of intestinal malrotation and midgut volvulus was established, and the patient underwent surgery. Intestinal malrotation leading to midgut volvulus is a paediatric emergency. Case report adult congenital intestinal malrotation. Using the bowel grasper, the volvulus was derotated in an anticlockwise direction and restored to its normal anatomical position. Operative findings showed a mild volvulus with neither congestion nor ischemic change of the twisted bowel. Malrotation is defined as an abnormal rotation of the duodenum andor caecum around the sma axis, with variable fixation of the midgut to the retroperitoneum 1. Intestinal malrotation and volvulus in infants and children.
Congenital intestinal malrotation is a gastrointestinal anomaly whose most serious complication is midgut volvulus. Intestinal malrotation presenting with midgut volvulus in an. However, this symptom is not synonymous with the diagnosis of malrotation. Midgut malrotation refers to twisting of the entire midgut about the axis of the superior mesenteric artery sma. Red dotted lines represent the path of sma and its branches. Midgut volvulus occurs most often in the context of congenital intestinal malrotation, in which the small intestine is not normally fastened in place. Transabdominal ultrasound demonstrated a round softtissue masslike structure in the right upper quadrant. Intestinal malrotation and volvulus childrens hospital of. We present our experience to emphasize the importance of suspecting midgut volvulus as a cause of abdominal pain also beyond infancy, particularly in relation to malrotation, and the relevance of ultrasonographic us signs in its diagnosis. The second complication is duodenal obstruction due to ladds band. Diagnosis and surgical management of congenital intestinal.
Thirty four neonates presented with acute duodenal obstruction due to malrotation during a 9 year period between 1973 and the end of 1981. Midgut volvulus midgut volvulus is a different clinical entity and is most common in children. The classic presentation of malrotation with acute midgut volvulus is a neonate with bilious emesis. Computed tomography showed an intestinal malrotation, without the duodenum crossing the midline and with the colic frame arranged in the left hemiabdomen figure 1, complicated with a midgut volvulus as demonstrated by the whirlpool sign figure 2, arrow.
Intestinal malrotation, which is defined by a congenital abnormal position of the duodenojejunal junction, may lead to midgut volvulus, a potentially lifethreatening complication. In patients with acute obstruction, this differential should be kept in mind, especially if the patient has no previous abdominal surgery or evidence of tuberculosis. Intestinal malrotation is more commonly diagnosed in the neonatal period, while adult presentations are reported with an incidence of 0. Malrotation pediatrics clerkship the university of chicago. Symptomatic malrotation occurs in 16000 live births. We present our experience to emphasize the importance of suspecting midgut volvulus as a cause of abdominal pain also beyond infancy, particularly in relation to malrotation, and the relevance of ultrasonographic us signs in. Malrotation in adults may present in an acute way due to midgut volvulus or may have a chronic indolent course with recurrent vomiting and abdominal pain. Ultrasonographic diagnosis of midgut volvulus with. It may result in proximal bowel obstruction with resultant ischemia if prompt treatment is not instigated.
The surgery done for midgut volvulus is called as a ladds procedure and is the preferred choice of treatment for midgut volvulus. Malrotation results in narrow and long base of mesentery which predisposes bowel to twist around it. Intestinal malrotation is a pathological condition which results due to an underdeveloped intestine. Midgut volvulus with malrotation is typical in newborns.
Malrotation can lead to a dangerous complication called volvulus malrotation can refer to a spectrum of abnormal intestinal positioning, often including. The clinical course is acute with rapid progression to midgut ischemia, unstable hemodynamics, intractable metabolic acidosis. Spectrum of clinical and imaging features original research. Intestinal malrotation an overview sciencedirect topics. The study includes all cases in which midgut volvulus was prenatally suspected after ultrasound. While most patients present during the neonatal period or the first year of life, some present as older children or adults. Case report adult congenital intestinal malrotation accompanied by midgut volvulus. See intestinal malrotation in children, section on epidemiology. Ct angiographic demonstration of mesenteric vessel whirlpool in intestinal malrotation and midgut volvulus korean j radiol 95, october 2008 467 ab fig.
Pdf a fourdayold boy presented with persistent bilious vomiting, bloody stained stool, and mild abdominal distension. The main presentation of intestinal malrotation is bilious vomiting and abdominal distension. Malrotation may result from predisposing genetic mutations and are often found in conjunction with other congenital malformations 1, 2, 5, 10. At the fourth week of gestation, the gi system is a straight tube centrally located in the abdomen. Any child with bilious vomiting must be assumed to have midgut volvulus until proven otherwise. Embryology, signs and symptoms, diagnosis and treatment for students taking.
Infants with malrotation and midgut volvulus often are described as having bilestained emesis, abdominal distention, and peritoneal signs and may appear ill. Nov 26, 20 up to 80% of patients present in the first month of life,2 and in this age group the cardinal symptom is bile green vomiting due to duodenal obstruction through midgut volvulus. A fourdayold boy presented with persistent bilious vomiting, bloody stained stool, and mild abdominal distension. Duodenum with corkscrew appearance in intestinal malrotation contrast study in duodenal atresia barium enema intestinal malrotation barium enema image of transverse colon cutoff due to midgut vol ileus plain radiograph of an infant with duodenal atresia ct whirlpool sign of midgut volvulus. Malrotation with gastric volvulus, midgut volvulus, and. Often volvulus occurs about the superior mesenteric artery axis, which results in ischemia of regions supplied by the artery, from duodenum to the splenic flexure. Kenney introduction malrotation is a spectrum of anatomic abnormalities of incomplete rotation and fixation of the intestinal tract during foetal development. Oblique digital subtraction angiogram a of patient depicting barbers pole sign arrows due to rotations of superior.
The most common clinical presentation of midgut volvulus is bilious vomiting, which is a nonspecific sign of intestinal obstruction. Such patients pose a unique challenge for the surgeon acutely both from a diagnostic and treatment standpoint. A 2yearold child with intestinal malrotation had simultaneous gastric volvulus, midgut volvulus, acute pancreatitis, and gastric perforation, followed postoperatively by a temporary period of both lactosuria and sucrosuria. The prevalence of volvulus is difficult to quantify, but any patient with malrotation is considered at a risk of midgut volvulus despite the critical nature of this condition and the need for prompt surgical correction, many reports show delay between the onset of symptoms and surgical intervention 2 3 4. Pdf the surgery of malrotation and midgut volvulus. Midgut volvulus most patients with malrotation develop midgut volvulus within the first weeks of life. In three patients, the twisted, corkscrew appearance of the barium column in the duodenum and proximal jejunum in an upper gastrointestinal series made the diagnosis. Congenital abdominopelvic cysts or masses can cause both high and low usually partial. Because of its rarity, the diagnosis of intestinal malrotation in adult patients is often delayed and therefore associated with increased morbidity. Vomiting was the sympton of paramount importance in 97% but was not initially bilestained in 20%. Pdf intestinal malrotation and midgut volvulus researchgate.
Learningradiology malrotation with a midgut volvulus. Characteristics of the patients, the pregnancy, and the delivery are presented in table 1, case by case. Successful outcome of this clinical condition depends on prompt diagnosis and timely surgical intervention. An evaluation for malrotation is part of every upper gastrointestinal gi tract examination in pediatric patients, particularly neonates and infants. Case 4 a boy born at term in no distress was placed in the wellbaby nursery.
Sonographic findings of midgut malrotation with volvulus. This case describes an 80yearold female with marfan syndrome presenting with primary midgut volvulus, which preoperatively was suspected based on imaging, and. The clinical manifestations, diagnosis, and treatment of intestinal malrotation in adults will be discussed in this topic. Malrotation with midgut volvulus can be a catastrophic event resulting in intestinal ischemia and shock, and it represents a surgical emergency in the neonate. Midgut volvulus was diagnosed most often during the third trimester, with peaks at 27 n. Intestinal malrotation with midgut volvulus is an important surgical emergency in pediatric practice.
Gut malrotation, nonrotation and volvulus for usmle youtube. Pdf malposition of the intestine malposition malrotation. History and clinical examination a 10 yr old female patient comes to casualty with complaints of pain in epigastric region which was acute in onset since 24 days bilious vomiting since 24 days a lump was felt in the epigastrium with localised tenderness temperature was slightly raised rest parameters were within normal limits. Volvulus of the cecum, transverse colon, or sigmoid colon occurs, usually in adults, with only minor predisposing factors such. Disorders of intestinal rotation and fixation are of paramount impor. Chapter 65 intestinal malrotation and midgut volvulus johanna r. Midgut volvulus becomes symptomatic within 1 month after birth in 80% of cases. All of the small bowel was examined and determined to be completely viable. Epidemiology a midgut volvulus of malrotated bowel can potentially occur at any ag. A volvulus is a problem that can occur after birth as a result of intestinal malrotation. This frequent association is stressed as bowel necrosis occurs very rapidly.
Midgut volvulus was diagnosed most often during the third trimester, with peaks at 27 n 5 and 32 weeks of gestation n 6. Primary midgut volvulus is a term used when there is no underlying cause for the volvulus. A diagnosis of malrotation was established in only 1 patient, whereas the other 6 were diagnosed on laparoscopy. The differential diagnoses for low intestinal obstruction include ileal and colonic atresia, anorectal malformation, meconium ileus, colonic dysmotility syndromes, and hirschsprungs disease.
Malrotation and volvulus due to the risk for loss of bowel, any infant with bilious emesis must be evaluated for malrotation and volvulus. Sep 19, 2019 a nasogastric tube was placed and fluid therapy started. The authors have declared that no competing interests exist. The midgut can at any time twist around its narrow mesenteric pedicle resulting in a midgut volvulus. Ct angiographic demonstration of a mesenteric vessel. Differentiating connective tissue diseaseassociated interstitial lung disease from idiopathic pulmonary fibrosis. In 1923 dott 4 applied this knowledge to the clinical problem of volvulus and intestinal obstruction. Gut malrotation, nonrotation, and volvulus is arrest of the normal gut as it rotates around the super mesenteric artery. Ugi duodenal bulb volvulus corkscrew duodenum with corkscrew appearance in intestinal malrotation contrast study in duodenal atresia barium enema intestinal malrotation barium enema image of transverse colon cutoff due to midgut vol ileus plain radiograph of an infant with duodenal atresia ct whirlpool sign of midgut volvulus plain radiographs necrotizing. Congenital intestinal malrotation in adolescent and adult patients. Chapter 28 covers intestinal malrotation and midgut volvulus, and includes information on definition, demographics, clinical features, anatomy, imaging modalities and features, imaging algorithm, applied physics, differential diagnoses and pitfalls, and a bulleted summary of key points. The study included cases of fetal midgut volvulus during the study period.
A knowledge of embryology is necessary to understand the mechanisms that lead to the development of volvulus and malrotation. All patients were men with an average age of 33 years. Corkscrew duodenum in malrotation with a midgut volvulus. Portal venous gas in intestinal malrotation with mild. Progressive bowel strangulation then results in an ischemic loss of extensive bowel. Intestinal malrotation is congenital abnormal positioning of the bowel loops within the peritoneal cavity resulting in abnormal shortening of mesenteric root that is predisposed to midgut volvulus. The developmental basis for malrotation and malfixation of the midgut was first described by mall in 1898. Four presented with long histories of intermittent abdominal pain. Midgut volvulus is a lifethreatening complication of intestinal malrotation that should be diagnosed early and treated properly to avoid sepsis and mortality. Detorsion and ladd s procedure were completed laparoscopically.
Rotation abnormalities represent a spectrum from nonrotation to normal rotation. Characteristics of the patients, the pregnancy, and the delivery are presented intable 1, case by case. Congenital intestinal malrotation, midgut volvulus, computed tomography introduction congenital intestinal malrotation is a complex gastrointestinal anomaly, which could easily lead to midgut volvulus and gastrointestinal obstruction. This condition usually begins in the first trimester around the 10th week in pregnancy. However, because having malrotation places the infant at an increased risk for a midgut volvulus. Neonatal malrotation with midgut volvulus mimicking duodenal. Segmental volvulus occurs in people of any age, usually with a predisposition because of abnormal intestinal contents e.
Patients with intestinal nonrotation have a lower incidence of midgut volvulus than other types of malrotation. Nevertheless, the presentation may vary from lifethreat ening acute ischemic midgut volvulus to. Early diagnosis and surgical intervention are needed to prevent gangrene of the midgut and peritonitis. Intestinal malrotation is a congenital anomaly of rotation of the midgut. Intestinal malrotation is a very common cause of midgut volvulus in the pediatric population. Intestinal malrotation and volvulus in infants and.
During the open surgery procedure, the entire intestine was seen free in abdominal cavity. Intestinal malrotation occurs when the normal rotation of the embryonic gut is arrested or disturbed during in utero development. The gastric volvulus and midgut volvulus resulted in both proximal and. With color doppler ultrasound, the whirlpool sign was observed. It is particularly important to recognize intestinal malrotation and midgut volvulus as mimics of the doublebubble sign.
However, more boys have symptoms by the first month of life than girls. Variants include incomplete, nonrotation, or reversed rotation. Jun 22, 2016 the diagnosis of intestinal malrotation with midgut volvulus was established and the treated surgically. In cases midgut volvulus, ultrasound can be the first noninvasive, radiation free, mostly available, and inexpensive imaging modality to start with. Given his acute presentation, operative intervention was the natural trajectory in his management.
Jun 05, 2015 midgut malrotation refers to twisting of the entire midgut about the axis of the superior mesenteric artery sma. In the infant, the most common presentation is with a midgut volvulus. This video shows a stepwise laparoscopic ladd procedure done in a day old female infant who presented with. The point of obstruction is typically beyond the ampulla of vater, as demonstrated by the bilious emesis. The gastric volvulus and midgut volvulus resulted in both proximal and distal obstruction of the duodenum, reproducing clinically a previously reported experimental model designed to produce pancreatitis. This problem can be managed surgically through a laparoscopic ladd procedure. The clinical presentation of malrotation often correlates with the age of onset 5.
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