gut malrotation
DR. ANAM FATIMA
PGR PAEDS MEDICINE
NISHTER HOSPITAL,
MULTAN
learning objectives
At the enD OF THIS SESSION, PARTICIPANTS WILL BE ABLE
TO:
>dEFINE GUT MALROTATION.
>UNDERSTAND THE NORMAL GUT
ROTATION DURING EMBRYOGENESIS.
>COMPREHEND THE PATHOPHYSIOLOGY OF
GUT MALROTATION.
>IDENTIFY THE CLINICAL FEATURES
>OUTLINE A MANAGEMENT PLAN.
GUT MALROTATION
INCOMPLETE ROTATION OF INTESTINE
DURING FETAL DEVELOPMENT;
INVOLVES INTESTINAL NON-ROTATION
OR INCOMPLETE ROTATION AROUND
SUPERIOR MESENTERIC ARTERY.
NORMAL GUT ROTATION
• Gut starts as a straight tubefrom stomach to rectum,
divided into 3 main parts- Foregut, Midgut, Hindgut.
• Midgut forms intestinal portion starting from 2nd part of
duodenum to right 2/3rd of transverse colon.
• At 5th week of gestation, Midgut begins to elongate and
progressively protrudes into the umbilical cord until it
lies totally outside the confines of abdominal cavity.
• A total of 270 degrees rotation takes place in
anticlockwise position.
NON ROTATION
When bowel fails to rotate after it
returns to the abdominal cavity. 1st
and 2nd portion of duodenum are in
their normal positions and rest of the
duodenum, jejunum, ileum occupy the
right side of abdomen and colon is on
left side
ASSOCIATIONS
1. Congenital diaphragmatic hernia
2. Gastroschisis
3. Omplaocele
4. Duodenal atresia/stenosis
5. Heteretaxy syndromes (complex of
congenital anomalies)
• Congenital heart malformations
• Biliary atesia
• Asplenia/Polysplenia
incidence
Reported incidence is 1:500
infants.
75%-85% present in 1st year of
life.
>50% present in 1st month of life
• The most common type of malrotation
involves failure of the cecum to move
into the right lower quadrant. The
usual location of the cecum is in the
subhepatic area.
• The mesentery, including the superior
mesenteric artery, is tethered by a
narrow stalk, which can twist around
itself and produce a midgut volvulus.
• Bands of tissue (Ladd bands) can
extend from the cecum to the right
upper quadrant, crossing, and possibly
obstructing, the duodenum
CLINICAL
MANIFESTATIONS
vOMITING abdominal pain
episodes of recurrent
Usually bilious emesis in
abdominal pain that can mimic
the 1st week of life.
colic and suggest intermittent
volvulus
Malbsorption Volvulus
malabsorption or protein- life-threatening
losing enteropathy complication of malrotation,
associated with bacterial which resembles an acute
overgrowth abdomen or sepsis
Diagnosis
1. Plain Abd Xray - demonstrates gasless abdomen or double-
bubble sign
(duodenal obstruction)
2. Ultrasonography - shows the inversion of the superior
mesenteric artery and
vein. A superior mesenteric vein located to the
left of the
superior mesenteric artery suggests
malrotation
3. Upper GI series (Contrast study)- Imaging test of choice
• visualize the malposition of the ligament of Treitz
• reveal a corkscrew appearance of the small bowel
• duodenal obstruction with a bird's beak appearance of the
duodenum.
The corkscrew sign describes the spiral appearance of the distal duodenum and proximal
jejunum seen in midgut volvulus. In patients with malrotation and volvulus, the distal
duodenum and proximal jejunum do not cross the midline and instead pass in an inferior
direction.
The whirlpool sign of the mesentery, also known as the whirl sign, is seen when the bowel
rotates around its mesentery leading to whirls of the mesenteric vessels.
Birds’s beak sign
An upper gastrointestinal imaging
study is shown that demonstrates
contrast in the stomach and
proximal duodenum. The distal
duodenum does not cross midline
and there is an abrupt cut-off
consistent with the diagnosis of
malrotation with midgut volvulus.
treatment
• Surgical intervention is recommended for any patient
with a significant rotational abnormality, regardless of
age.
• If a volvulus is present, surgery is done immediately as
an acute emergency, the volvulus is reduced.
• The Ladd procedure may be done laparoscopically for
malrotation without volvulus and if gut ischemia is not
present, but
it is generally done as an open procedure if volvulus is
present
ladd procedure
The Ladd procedure includes a
reduction of volvulus, lysis of Ladd
bands, placing the small bowel in the
right abdomen and the colon in the
left abdomen, and an appendectomy.
Thank you!
ANY
QUESTIONS?
