INTESTINAL MALROTATION

INTESTINAL MALROTATION NT44 GIANG CASE 1: Male 57 year-old Clinical presentation: abdominal pain around the navel, guarding sign  Fever 38 Case 2: Case 3: day-old girl, bilious vomiting, hematochezia INTRODUCTION Intestinal malrotation is a congenital anatomical anomaly that results from an abnormal rotation of the gut as it returns to the abdominal cavity during embryogenesis Intestinal malrotation occurs in between in 200 and in 500 live births Symptomatic malrotation occurring in only in 6000 live births https://www.youtube.com/watch?v=vJA1A0v6Aa4 CLINICAL PRESENTATION Infant: the most common presentation is with a midgut volvulus Occur at any age but in approximately 75% of cases occur within a month of birth Patients with intestinal nonrotation have a lower incidence of midgut volvulus than other The older child or adult is  frequently intermittent with episodes of spontaneously resolving duodenal obstruction( kinking by Ladd bands), Internal hernias Some, presentation is very non-specific with episodes of abdominal pain, weight loss, melena, even chronic pancreatitis Female 20 year-old, Occasional pain in abdomen of intermittent type; no history of vomiting 45 2h 4h days, Male, Bilious vomiting Barium meal demonstrates a cork-screw proximal jejunum, with the DJ-flexure never reaching the left side of the abdomen Figure 7b Midgut volvulus in an infant. (a) Upper GI image shows that the small bowel lies in the right side of the abdomen and does not cross the midline. (b) Lateral upper GI image shows the typical twisting corkscrew-like appearance of a volvulus of the proximal jejunum ULTRASOUND  Invert in the SMA/SMV relationship with the SMA on the right and the SMV on the left  A normal SMA/SMV relationship can be seen in up to 29% of patients with surgically proven malrotation Inverted relationship is seen in up to 11% of patients  abnormal bowel: Obstruction, Ischemia… ULTRASOUND Once a volvolus is diagnosed on ultrasound, the child should go straight to the operating room and no more time should be lost on further imaging clockwise whirlpool sign 3-week-old, male, vomiting A V year old female presented with intermittent incomplete small bowel obstruction yearl old female Recurrent abdominal pain CT scanner Depending on the degree of malrotation, CT may show: absence of a retro-mesenteric (retro-peritoneal) D3 segment of the duodenum 8 may again show abnormal SMA (smaller and more circular)/SMV relationship large bowel predominantly on the left and small bowel predominantly on the right absence of D3 segment of the duodenum traversing the left of the spine 35 yearl old male, Recurrent abdominal discomfort Abdominal axial CT with oral and IV contrast demonstrating right-sided small bowel and left-sided colon with oblique right-left inversion of the SMA (a) and SMV (v) consistent with congenital malrotation of the intestine https://radiopaedia.org/cases/intestinal-nonrotation-1 29-year-old man with acute abdominal pain and vomiting from malrotation with midgut volvulus His history was significant for similar prior episodes without diagnosis (Courtesy of Fleishman MJ, Denver, CO) Axial contrast-enhanced CT scans show characteristic whirllike appearance of bowel and mesentery wrapping around superior mesenteric artery (arrowheads, B) Note dilated duodenum (D, B), engorged mesenteric vessels (arrows, C), and underlying malposition of bowel Read More: https://www.ajronline.org/doi/full/10.2214/ajr.179.6.1791429 A 32-year-old man Insidious, progressive, constant pain in his left iliac fossa without radiation for two days Tenderness, rebound tenderness, guarding in left iliac fossa USG: a noncompressible, blindending, tubular structure with surrounding hyperechoic mesentery with probe tenderness in left iliac fossa without free fluid which we suspected to be leftsided acute appendicitis  Intraoperative findings showing appendix (unfilled block arrow) on the left side of the abdomen TREATMENT Surgical management of intestinal malrotation at any age is by the Ladd’s procedure [3] This procedure was first described by William Ladd in 1936 and consists of the following steps [2,12,18,19]: 1) Division of Ladd’s bands (fibrous bands) lying over the duodenum to the caecum 2) Widening of the narrowed root of the mesentery 3) Counterclockwise detorsioning of the midgut volvulus if present and inspecting the bowel to observe if bowel resection is required 4) Appendicectomy if required 5)Placing the small bowel to the right and fixing the colon to the left ... INTRODUCTION ? ?Intestinal malrotation? ?is a congenital anatomical anomaly that results from an abnormal rotation of the gut as it returns to the abdominal cavity during embryogenesis ? ?Intestinal malrotation. .. consistent with congenital malrotation of the intestine https://radiopaedia.org/cases /intestinal- nonrotation-1 29-year-old man with acute abdominal pain and vomiting from malrotation with midgut... a double bubble sign FLUOROSCOPY A upper gastrointestinal contrast study is the examination of choice when the diagnosis is suspected The key findings of malrotation is an abnormal duodenojejunal