Malrotation of Gut: Pravin Narkhede

MALROTATION OF GUT
PRAVIN NARKHEDE
Intestinal Rotation
• Intestinal malrotation as intestinal
nonrotation or incomplete rotation around
the superior mesenteric artery (SMA).
• The most common type found in pediatric
patients is incomplete rotation predisposing
to midgut volvulus, which can result in short-
bowel syndrome or even death.
Embryology
• Normal rotation takes place around the superior
mesenteric artery (SMA) as the axis.
• 2 ends of the alimentary canal,
– the proximal duodenojejunal loop and
– the distal cecocolic loop, and
• 3 stages of development
• Both loops make a total of 270° in rotation during
normal development.
• Both loops start in a vertical plane parallel to the
SMA and end in a horizontal plane
• Stage I
– 5-10 weeks' gestation
– physiologic herniation of the bowel into the base
of the umbilical cord
– The duodenojejunal loop begins superior to the
SMA at a 90° position and rotates 180° in a
counterclockwise direction. At 180°, the loop is to
the anatomical right of the SMA, and by 270°, it is
beneath the SMA.
– The cecocolic loop begins beneath the SMA at
270°. It rotates 90° in a counterclockwise manner
and ends at the anatomical left of the SMA at a 0°
position
– Both loops maintain these positions until the
bowel returns to the abdominal cavity.
– Also during this period, the midgut lengthens
along the SMA, and, as rotation continues, a very
broad pedicle is formed at the base of the
mesentery.
– This broad base protects against midgut volvulus.
- SMA is the axis.
- DJ loop (red arrow) & cecocolic loop (green arrow)
• Stage II
– 10 weeks' gestation, the period when the bowel
returns to the abdominal cavity.
– As it returns, the duodenojejunal loop rotates an
additional 90° to end at the anatomical left of the
SMA, the 0° position.
– The cecocolic loop turns 180° more as it reenters
the abdominal cavity. This turn places it to the
anatomical right of the SMA, a 180° position.
• Stage III
– 11 weeks' gestation
– the descent of the cecum to the right lower
quadrant and fixation of the mesenteries.
– Fixation of intestine to posterior body wall
• Ligament of Treitz
• Cecum to right iliac fossa
• Base of mesentery
• Ascending and
• Descending colon
Normal Rotation
Types of Malrotation
• Nonrotation
– Arrest in development at stage I
– DJ loop junction does not lie inferior and to the
left of the SMA, and the cecum does not lie in the
right lower quadrant.
– The mesentery forms a narrow base as the gut
lengthens on the SMA without rotation, and this
narrow base is prone to clockwise twisting leading
to midgut volvulus.
Nonrotation
• Incomplete rotation
– Stage II arrest , result in duodenal obstruction.
– peritoneal bands running from the misplaced cecum
to the mesentery compress the third portion of the
duodenum.
– Depending on how much rotation was completed
prior to arrest, the mesenteric base may be narrow
and midgut volvulus can occur.
– Internal herniations may also occur with incomplete
rotation if the duodenojejunal loop does not rotate
but the cecocolic loop does rotate.
– This may trap most of the small bowel in the
mesentery of the large bowel, creating a right
mesocolic (paraduodenal) hernia.
• Incomplete fixation
– Potential hernial pouches form when the
mesentery of the right and left colon and the
duodenum do not become fixed retroperitoneally.
– If the descending mesocolon between the inferior
mesenteric vein and the posterior parietal
attachment remains unfixed, the small intestine
may push out through the unsupported area as it
migrates to the left upper quadrant. This creates a
left mesocolic hernia with possible entrapment
and strangulation of the bowel.
– If the cecum remains unfixed, volvulus of the
terminal ileum, cecum, and proximal ascending
colon may occur
• Reverse Rotation
– Rare anomaly.
– Bowel rotates in
varying degrees in a
clockwise direction.
– DJ loop is anterior to
SMA & CC loop in
retroarterial leading to
colonic obstruction.
– Cecum maybe Right or
Left sided
Differential Diagnosis
• Bowel Obstruction in the Newborn

• Duodenal Atresia
• Gastroesophageal Reflux
• Intestinal Volvulus
• Necrotizing Enterocolitis
• Neonatal Sepsis
Clinical Presentation
• Male to Female ratio of 2:1
• 40% prsent in 1st week
• 50% by age 1 month & 75% by age 1 year.
• 25% of patients present after age 1 year and
into late adulthood
• varies in patients with intestinal malrotation
according to acute or chronic presentation &
according to type of rotational defect
• Midgut Volvulus
• Acute
– first year of life
– primary presenting sign bilious emesis.
• Chronic
– due to intermittent or partial twisting that results
in lymphatic and venous obstruction
– recurrent abdominal pain and malabsorption
syndrome
– recurrent bouts of diarrhea alternating with
constipation,
– intolerance of solid food, obstructive jaundice and
gastroesophageal reflux
Midgut Volvulus
• Duodenal Obstruction
• Acute
– due to compression or kinking of the duodenum by
peritoneal bands (Ladd bands).
– forceful vomiting, which may or may not be bile-
stained, depending on location of the obstruction
with respect to the entrance of the common bile duct
(ampulla of Vater).
• Chronic
– infancy to preschool-age
– most common symptom is vomiting, which is usually
bilious.
– failure to thrive and intermittent abdominal pain
(frequently diagnosed as colic).
Ladd’s band
• Internal Herniation
– usually has a chronic picture
– recurrent abdominal pain, which may progress
from intermittent to constant.
– vomiting as well as constipation at times.
– They are often diagnosed with psychosocial
problems.
Diagnosis
• Routine blood examination
• Serum electrolytes
Imaging Studies
• Plain abdominal radiography

– limited use for defining obstruction because
infants may have a gasless abdomen or almost
normal
– duodenal obstruction, if present shows the
double-bubble sign
• Upper GI series
– Study of choice in patients who are stable
– contrast ends abruptly or tapers in a corkscrew
pattern, midgut volvulus or some other form of
proximal obstruction may be present
• Diagnostic Findings
– Abnormal position of duodenum (Ligament of
Treitz on right)
– Duodenal obstruction
– Beak appearance of duodenum with volvulus
• Lower GI series (contrast enema)
– rule out colonic obstruction and ileal atresia.
However, a normally placed cecum does not
unequivocally rule out a malrotation,
– Not very helpful
• Ultrasonography
– very sensitive (approximately 100%) in detecting
neonatal malrotation.
– Highest sensitivity is achieved when inversion of
the superior mesenteric artery (SMA) and the
superior mesenteric vein (SMV) is shown
– diagnostic findings are fixed midline bowel loops
and duodenal dilation with distal tapering
– volvulus is highly probable if the SMV is shown to
be coiling around the SMA.
– All features are enhanced if water is instilled first
by nasogastric (NG) tube.
• CT scan
– not well developed for diagnosing malrotation
and midgut volvulus
– not recommended as the principal diagnostic tool.
Treatment
• NG tube insertion
– to decompress the bowel proximal to any
obstruction that may be present.
• Central venous catheter placement
– especially if midgut volvulus is present.for
intravenous nutrition is likely to be necessary
• Medical Care
– stabilizing the patient
– Correct fluid and electrolyte deficits
– Administer broad-spectrum antibiotics prior to
surgery
– Corret hypotension with appropriate fluids, blood
products, and vasopressor, dopamine 1st choice
because of its possible effects to increase
splanchnic blood flow infusion rate of 3
mcg/kg/min intravenously (IV)
– Quick surgical intervention is needed
• Surgical Care
• Ladd procedure
– Cornerstone of surgical treatment
– Detorsion of Midgut Volvulus
– Lysis of adhesive bands
– Placement of Small bowel in non rotated position
on the right side of abdominal cavity.
– Placement of Large bowel on the left side of
abdominal cavity.
– Inversion Appendectomy
Ladd’s Procedure
• Midgut volvulus
– volvulus usually twists in a clockwise direction,
reduction is accomplished by twisting in a
counterclockwise direction
– After the blood supply has been restored by detorsion
• Viable bowel – good outcome
• Gangrenous bowel – resecton & anastomosis
– Enterostomy is performed when questionable viability
is observed at the ends of a gangrenous area that is
resected.
– If multiple areas of questionable viability are present,
many surgeons choose to leave the areas and perform
a second-look operation in 12-24 hours if the patient
is not showing clinical recover
• Duodenal obstruction
– volvulus is reduced
– Identify any extrinsic obstruction to the duodenum
– peritoneal bands crossing the duodenum are found,
ligate them with careful attention to protecting the
superior mesenteric vessels.
– Extrinsic obstruction may also be due to the cecum,
colon, or superior mesenteric artery (SMA) impinging
on the duodenum; relief is obtained by placing the
cecum with its mesentery in the left upper quadrant
and exposing the anterior duodenum through its
entire length.
– determine that no intrinsic obstruction exists by
passing an NG tube through the duodenum.
• Appendectomy
– dissection of the peritoneal bands causes damage
to the appendiceal vessels.
– advisable because the normal anatomical
placement of the appendix is disrupted when the
cecum is placed on the left side of the abdomen
• Laparoscopy
– used to repair malrotation with signs of duodenal
obstruction but no midgut volvulus.
– The Ladd procedure, including widening of the
mesenteric base and dissection of peritoneal
bands, has been performed successfully and has
resulted in shorter hospital stays.
Complications
• Short-bowel syndrome
– the most common complication of midgut
volvulus., 18%
• Wound Infection
• Recurrent volvulus is relatively infrequent but
must be of prime concern in patients
presenting with obstructive symptoms
• Postoperative obstruction commonly due to
adhesive bands.
Prognosis
• In general, older children do better than
infants.
• The presence of midgut volvulus prolongs
hospitalization, and prognosis is based on how
much bowel is preserved.

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MALROTATION OF GUT

• Bowel Obstruction in the Newborn

• Plain abdominal radiography

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