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Intestinal
Malrotation
Case # 608324
Case # 608324
By:
Roshni Patel &
Preeti
Rani
6/13/2006
2
The Chief Complaint
•<=
/span>Pt c/o early satiety and bloating
•<=
/span>HPI – 38 yo Hispanic male presented to the c=
linic
on 12.21.05
–<=
/span>c/o post - prandial fullness with minimal pain. &#=
13;
–<=
/span>Started reglan in combination with prevacid
–<=
/span>In f/u visit pt was still c/o abd distension while
eating
–<=
/span>Constant feeling of gas
–<=
/span>Denies nausea, vomiting, diarrhea, hard stool, mel=
ena,
& hematochezia
=
–<=
/span>Denied wt loss, fevers, chills, night sweats, anorexia
–<=
/span>Denied urinary complaints
–<=
/span>Denied any weight loss
6/13/2006
3
Medical History
<=
span
class=3DBB style=3D'position:absolute;left:-4.26%'>•PMHx R=
11;
Denied
<=
span
class=3DBB style=3D'position:absolute;left:-4.26%'>•PSHx R=
11;
Denied
<=
span
class=3DBB style=3D'position:absolute;left:-4.26%'>•Medicatio=
ns
– None
<=
span
class=3DBB style=3D'position:absolute;left:-4.26%'>•Allergies=
–
NKDA
<=
span
class=3DBB style=3D'position:absolute;left:-4.26%'>•FHx ̵=
1;
Denied
<=
span
class=3DBB style=3D'position:absolute;left:-4.21%'>•SHx ̵=
1;
Denied smoking, drugs, and EtOH
6/13/2006
4
Physical Exam
•<=
/span>Vitals – T: 98.6 HR:89 RR: 20 BP: 130/80
•<=
/span>General:AAOx3, NAD
•<=
/span>HEENT: PERRL, EOMI, nares patent, no erythema of <=
/span>throat
•<=
/span>Neck: supple, no LA
•<=
/span>CVS: S1, S2 no m/r/r, RRR
•<=
/span>Resp: CTA B/L no w/r/r
•<=
/span>Abd: soft, +BS, mild tenderness to palpation, no <=
/span>=
guarding or rebound tenderness, no abd distension&=
#13;
•<=
/span>Ext: FROM, + Pulses
6/13/2006
5
Labs
<=
span
class=3DHBB style=3D'position:absolute;left:-9.3%'>•CBC
<=
/span>
=
;
14.3
6.4 43.5 307
<=
/div>
<=
span
class=3DHBB style=3D'position:absolute;left:-9.3%'>•BMP
<=
/span>
142 107 13 96&=
#13;
4.4 28 0.9 9
&#=
8226;LFT’s
=
–Albumin
– 4.0
=
–Total
Protein – 6.7
=
–ALT
– 29
=
–AST
– 27
=
–T.
Bilirubin – 0.5
=
–Direct
Bilirubin – 0.1
=
–Alk
Phos - 74
![](3D"slide0051_image002.gif")
![](3D"slide0051_image003.gif")
![](3D"slide0051_image004.gif")
![](3D"slide0051_image005.gif")
![](3D"slide0051_image006.gif")
![](3D"slide0051_image007.gif")
![](3D"slide0051_image008.gif")
6/13/2006
6
Differential Diagnosis
<=
span
class=3DHBB style=3D'position:absolute;left:-9.3%'>•Intestinal
obstruction
<=
span
class=3DHBB style=3D'position:absolute;left:-9.3%'>•Meconium
Ileus
<=
span
class=3DHBB style=3D'position:absolute;left:-9.3%'>•Sepsis=
3;
<=
span
class=3DHBB style=3D'position:absolute;left:-9.3%'>•Incacerat=
ed
hernia
<=
span
class=3DHBB style=3D'position:absolute;left:-9.3%'>•Acute
abdomen
<=
span
class=3DHBB style=3D'position:absolute;left:-8.06%'>•Necrotiz=
ing
enterocolitis
<=
span
class=3DHBB style=3D'position:absolute;left:-9.3%'>•Intussusc=
eption
<=
span
class=3DHBB style=3D'position:absolute;left:-9.3%'>•Perforate=
d viscus
<=
span
class=3DHBB style=3D'position:absolute;left:-9.3%'>•Appendici=
tis
<=
span
class=3DHBB style=3D'position:absolute;left:-9.3%'>•Peritonit=
is
6/13/2006
7
AXR =
;
UGI Series
•No evidence of bowel obstruction
•No pneumoperitoneum is present
•Th=
e 3rd=
port=
ion of
the duodenum does not=
cross
the ligament of Treitz
– indicating
malrotation
•Several loops of dilated bowel in RLQ
–May represent internal abd hernia with partial obstruction or changes secondary to adhesions
•No evidence of esophagitis, gastritis, or duodenitis
6/13/2006
8
Operative Procedure
•<=
/span>Pt brought to OR under general anesthesia
•<=
/span>Placed foley – clear urine
•<=
/span>Placed NGT
•<=
/span>Abd was opened and explored
•<=
/span>Adhesions found in RUQ
–<=
/span>kinked the duodenum as it entered the stomach
=
–Adhesions were taken down to expose the surface of=
the 3rd=
, 2nd=
, and 1st portion of the duodenum heading in=
to the
stomach
•<=
/span>Mesentery of the bowel was rotated clockwise for <=
/span>=
approx. one full turn
•
6/13/2006
9
Procedure cont.
•Bowel was viable
•In one 360 degree
counterclockwise turn the small bowel was untwisted
•Placed the small bowel=
on
R side of the abd and the colon, cecum, r colon, transvers=
e,
and L colon
on the L side of the abd
•Appendix was intact and
appendectomy was done
•Abd was closed<=
/div>
6/13/2006
10
Post – Op Labs
<=
span
class=3DHBB style=3D'position:absolute;left:-9.3%'>•POD #1=
3;
<=
span
class=3DHBB style=3D'position:absolute;left:-9.3%'>•131 98 6 131=
4.2 29 0.8 8.0
<=
span
class=3DHBB style=3D'position:absolute;left:-9.3%'>•10.2 13.7
254
=
;
39.7
<=
span
class=3DHBB style=3D'position:absolute;left:-9.3%'>•Mg 1.6 Phos 3.3
<=
span
class=3DHBB style=3D'position:absolute;left:-9.3%'>•POD #2=
3;
135 99 1 120=
5.0 32 0.1 8.7
<=
/div>
<=
span
class=3DHBB style=3D'position:absolute;left:-9.3%'>•Mg 1.7 Phos 2.3
<=
span
class=3DHBB style=3D'position:absolute;left:-9.3%'>•POD #3=
3;
137 104 6
99
4.1 27 0.8 8.6
![](3D"slide0032_image009.gif")
![](3D"slide0032_image010.gif")
![](3D"slide0032_image011.gif")
![](3D"slide0032_image012.gif")
![](3D"slide0032_image013.gif")
![](3D"slide0032_image014.gif")
![](3D"slide0032_image015.gif")
![](3D"slide0032_image016.gif")
![](3D"slide0032_image017.gif")
![](3D"slide0032_image018.gif")
![](3D"slide0032_image019.gif")
![](3D"slide0032_image020.gif")
![](3D"slide0032_image021.gif")
![](3D"slide0032_image022.gif")
![](3D"slide0032_image023.gif")
6/13/2006
11
Intestinal Malrotation
•A
congenital anomaly
•Rotation o=
f the
midgut where the small bowel is found on the right side of the abdomen & the cecum is
found in the subpyloric
region
•I=
ntestines
are attached by a narrow base
–T=
he
midgut is prone to twisting (or volvulus)
–O=
bstruct
the mesenteric vessels and cause intestinal ischemia.
6/13/2006
12
Epidemiology
•<=
/span>In the US
–<=
/span>1 in 500 =
live
birth
– Most infants with gastroschisis,
omphalocele, or congenital diaphragmatic hernia present with intest=
inal
malrotation
–<=
/span>~ 50% of patients with duodenal atresia & 33% of patien=
ts with jejunoileal atresia
–<=
/span>Associated with Hirschsprung dx, gastroesophageal reflux, <=
/span>intussusception, persistent cloaca, anorectal malformations,
& extrahepatic anomalies
6/13/2006
13
Epidemiology
&#=
8226;Rotational
anomalies
&=
#8211;Symptomatic
&=
#8226;1/200
and 1/500 live births
&=
#8211;Asymptomatic
&=
#8226;1/6000
live births
=
226;~
2/3 of children who require surgery are < 1 moa
&#=
8226;18
- 25% are between 1 mo and one yoa
&#=
8226;10
-18% are > 1 yoa
6/13/2006
14
Associated Anomalies
•30-62% of patients w=
ith intestinal
malrotation have an associated anomaly
•100% of =
children
with diaphragmatic hernia, gastroschisis, and =
=
omphalocele
![](3D"slide0034_image025.jpg")
6/13/2006
15
Embryology
•<=
/span>Arrest of normal rotation of the embryonic gut
=
;
•<=
/span>4th - 8th wks=
of
embryonic development, the embryonic coelom
cannot accommodate the rapidly expanding GI tract
–<=
/span>Primary intestinal loop buckles into the area of t=
he
yolk stalk, the future
umbilicus
•<=
/span>The axis of this loop is the developing SMA
•<=
/span>As the primary intestinal loop buckles out of the =
abdomen, it begins the normal rotation of the bowe=
l by twisting 90º counterclockwise
•<=
/span>This initial rotation is driven by two factors :&#=
13;
–<=
/span>Proximal bowel grows faster than the distal bowel =
–<=
/span>Rapid growth of the liver
•
6/13/2006
16
Embryology
•<=
/span>Primary loop continues to grow
<=
/div>
•<=
/span>Then returns to the abdomen during the 8th=
- 10=
th=
wks=
=
of gestation
•<=
/span>There is an additional 180º counterclockwise
rotation
•<=
/span>Overall the bowel rotates 270º counterclockwi=
se
from the original prima=
ry
loop
•<=
/span>At its final position, fixation to the posterior a=
bdomen
occurs
–<=
/span>The proximal portion of the bowel is fixed to the =
retroperitoneum early in gestation (at the ligamen=
t of
Treitz)
–Whereas fixation of the colon is gradual and usual=
ly completed near term
6/13/2006
17
![](3D"slide0035_image027.jpg")