Intestinal malrotation

Intestinal malrotation
Specialty	Medical genetics

Intestinal malrotation is a

• The small intestine found predominantly on the right side of the abdomen
• The
  right lower quadrant into the epigastrium or right hypochondrium
• An absent or displaced
  ligament of Treitz
• Fibrous peritoneal bands called
  bands of Ladd running across the vertical portion of the duodenum
• An unusually narrow, stalk-like mesentery

The position of the intestines, narrow mesentery and Ladd's bands can contribute to several severe gastrointestinal conditions. The narrow mesentery predisposes some cases of malrotation to midgut volvulus, a twisting of the entire small bowel that can obstruct the

Signs and symptoms of malrotation vary depending on age and whether the patient is suffering from an acute volvulus or experiencing chronic symptoms.^[citation needed]

• If the patient, most often neonatal, presents acutely with
  bilious emesis, crampy abdominal pain, occasional GI haemorrhage, abdominal distention, and in late cases, the passage of blood and mucus in their stools.^[1]
• Patients with
  chronic
  , uncorrected or undiagnosed malrotation can have recurrent abdominal pain and vomiting.
• Malrotation may be asymptomatic.[2]
• Postnatal presentation occurs with indistinct symptoms which can include abdominal migraine or pain, recurrent vomiting, failure to thrive, weight loss and other non-specific gastrointestinal issues.^[1]
• Adult presentation is often found due to symptoms associated with intestinal obstruction, ischaemia, and possibly necrosis, abdominal distention, elevated white blood cell count (particularly
  leucocyte and neutrophil counts)^[3]

Intestinal malrotation can lead to a number of disease manifestations and complications such as:^[citation needed]

• Acute midgut volvulus
• Chronic midgut volvulus
• Acute duodenal obstruction
• Chronic duodenal obstruction
• Short bowel syndrome, in cases of volvulus with intestinal necrosis
• Death, in cases of volvulus with pan-necrosis of the bowel, severe septic shock or hypovolemic shock
• Malabsorption
• Chronic motility issues
• Internal herniation
• Superior mesenteric artery syndrome

Causes

The exact cause of intestinal malrotation is unknown. It is not definitively associated with a particular gene, but there is some evidence of recurrence in families.[5]

Diagnosis

Malrotation is most often diagnosed during infancy, however, some cases are not discovered until later in childhood or even adulthood.^[6][2]

With acutely ill patients, consider emergency surgery laparotomy if there is a high index of suspicion.^{[citation needed]}

In cases of volvulus, plain radiography may demonstrate signs of duodenal obstruction with dilatation of the proximal duodenum and stomach but it is often non-specific. Ultrasonography may be useful in some cases of volvulus, depicting a "whirlpool sign" where the superior mesenteric artery and superior mesenteric vein have twisted.^[7]

The incidence of intestinal malrotation in infants with omphalocoele is low. Therefore, there is little evidence to support the screening for intestinal malrotation in infants with omphalocoele.[8]

Treatment

Prompt surgical treatment is necessary for intestinal malrotation when volvulus has occurred:^{[citation needed]}

• First, the patient is resuscitated with fluids to stabilize them for surgery
• The volvulus is corrected (counterclockwise rotation of the bowel),
• The fibrous Ladd's bands over the duodenum are cut,
• The mesenteric pedicle is widened by separation of the duodenum and cecum,
• The small and large bowels are placed in a position that reduces their risk of future volvulus

With this condition the appendix is often on the wrong side of the body and therefore removed as a precautionary measure during the surgical procedure.

This surgical technique is known as the "Ladd's procedure", after Dr. William Ladd.^[9][10] Long-term research on the Ladd's procedure indicates that even after surgery, some patients are susceptible to GI issues and may need further surgery.^[11]

See also

• Situs inversus, a congenital condition in which the major visceral organs are reversed or mirrored from their normal positions.

References