Malrotation of gut

Date: 30.07.2016
Venue: Classroom, Paediatric Surgery
Department, BSMMU
Presented by:
Dr. Mominul Haider
Phase-A Resident
MS (Urology)

Objectives
To discuss and understand -
• Normal rotation of gut
• Definition of Malrotation
• Presentation
• Investigation
• Treatment
• Complication

Introduction
• Malrotation refers to a group of congenital
anomalies resulting from aberrant intestinal
rotation and fixation.
• Incidence : 1/6000 live births
• No sex/race predilection

Normal rotation of gut
Stages of Normal Rotation
Herniation
Rotation
Retraction
Fixation

Physiologícal Herniation
• Development of the primary intestinal loop is
characterized by rapid elongation, particularly
of the cephalic limb.
• The abdominal cavity temporarily becomes
too small to contain all the intestinal loops,
and they enter the extraembryonic cavity in
the umbilical cord during the sixth week of
development

Rotation
• The primary intestinal loop rotates around an
axis formed by the superior mesenteric artery
• When viewed from the front, this rotation is
counterclockwise, and it amounts to
approximately 270° when it is complete
• Rotation occurs during herniation (about 90°)
as well as during return of the intestinal loop
into the abdomen (Remaining 180°)

Retraction
• During the 1Oth week, herniated intestinal loops
begin to return to the abdominal cavity.
• The proximal portion of the jejunum, the first part
to reenter the abdominal cavity, comes to be on
the left side
• The caecal bud is the last part of the gut to
reenter the abdominal cavity.

Key points in embryology
• Intestinal rotation starts at 5th week and
completes by 11th week
• Midgut is supplied by SMA
• Rotation takes place around SMA axis
• 270 degree counterclock wise rotation of
prearterial and post arterial limb.
• Ladds bands attach to the cecum irrespective
of its postion at the end of rotation from right
paracolic region.

Rotational disorders
Non rotation
Incomplete rotation
Reverse rotation

Nonrotation
• Neither colon or
duodenum undergo
rotation
• Most common form of
malrotation.
• M:F=2:1

Incomplete rotation
• Counter clock wise
rotation of only 180
• Caecum in the
epigastrium overlying
3rd part of duodenum.
• Most common form of
surgically treated
malrolation.

REVERSE ROTATION • Rotates clockwise.
• DJ loop anterior to SMA
and transverse colon
posterior to SMA.
• Causes compression of
colon by SMA -
obstruction.
• Ileocecal volvulus- due to
inadequate fixation of
right colon.

CLINICAL MANIFESTATIONS
• Asymptomatic
• Acute Midgut Volvulus – First month of life
• Chronic Midgut volvulus - children older than 2
years
• Acute duodenal obstruction secondary to
congenital bands - common in neonates and
infants

• Chronic duodenal obstruction secondary to
congenital bands
• Reverse rotation with colonic obstruction –
Rare, usually seen in adults
• Internal Hernia (Mesocolic hernia)
• Volvulus of the Caecum – seen in old patients

Presentation
 Usually in early age, but may present later in
life.
 75% present during 1st month of life.
 15% present within the 1st year.
• Bilious vomiting remains the cardinal sign of
neonatal intestinal obstruction, and
malrotation must be the presumed diagnosis
until proven otherwise.

• Other signs in the neonate include abdominal
pain and distention.
• The inconsolable infant may rapidly
deteriorate as metabolic acidosis quickly
advances to hypovolemic shock.
• Late signs include abdominal wall erythema
and hematemesis or melena from progressive
mucosal ischemia.

Acute Midgut Volvulus
• Sudden onset of bilious vomiting in a
previously healthy, growing infant.
• With the onset of proximal intestinal
obstruction, the distal colon empties; lower
abdomen may appear scaphoid.
• As vascular compromise progresses,
intraluminal bleeding may occur and blood is
often passed per rectum.
• Crampy abdominal pain is common.

Acute duodenal obstruction
• An infant or newborn usually presents with
forceful, bilious vomiting.
• Abdominal distention may or may not be
present
• The obstruction may be complete or
incomplete, so meconium or stool may have
been passed.
• Jaundice may be seen

Radiologic Diagnosis of Abnormalities of
Rotation and Fixation
• Radiologic studies play a critical role in
establishing a diagnosis of intestinal
malrotation.

Plain radiograph
• Right-sided jejunal markings
• Absence colonic shadow in RIF
• Features of complications
- Dilated bowel loops
- Air fluids levels
- Pneumoperitoneum

Contrast X Ray
• Delineation of the duodenojejunal junction
remains the most important diagnostic tool.
• The duodenum should be seen traveling across
the spine to the left.
• Additionally, the lateral film will show the
duodenum obtaining a retroperitoneal, posterior
position.

• Abnormal findings include
– positioning of the duodenojejunal flexure to the right
of the spine, obstruction of the duodenum
– The “coil spring,” “corkscrew,” or “beak” appearance
of the obstructed proximal jejunum
• Double-bubble sign in acute duodenal
obstruction.
• Gasless abdomen in midgut volvulus (gut is filled
with fluid)

Normal position and fixation of Duodenum

“Double bubble” in duodenal obstruction

Ultrasound
• Reversal of the normal anatomic relationship
between the SMA and
• “whirlpool sign” - midgut volvulus.

CT Abdomen
• Anatomic location of small bowel on right and
colon on left
• Relationship of the superior mesenteric
vessels – “vertically placed or inverted sides”
• Aplasia of the uncinate process
• Features of volvulus / obstruction / gangrene
• Other associated anomalies

Reversal of SMA and SMV Whirlpool sign

Treatment
Aim of treatment- Reduce the recurrence of
volvulus, not the position.

Preoperative preparation
• Aggressive resuscitation with fluid &
electrolyte.
• Intravenous broad spectrum antibiotics.
• Taken to the operating room for immediate
exploration.
• Placement of a Nasogastric tube.

• 2nd look operation is usually performed when
there are multiple areas of bowel of
questionable viability, when the entire midgut
appears nonviable, or when clinical signs &
symptoms suggest progressive loss of
intestine

Post operative care
• Nasogastric decompression
• Total parenteral nutrition until return of bowel
function.

Complications
• Diarrhea & dehydration in short bowel
syndrome
• Postoperative intussusception
• Postoperative adhesion
• Recurrent volvulus

References
• Pediatric surgery. —7th ed. / editor in chief,
Arnold G. Coran ; associate editors, N. Scott
Adzick . . [et al.]
• Ashcraft’s pediatric surgery / [edited by]
George Whitfield Holcomb III, J. Patrick
Murphy ; associate editor, Daniel J. Ostlie. —
5th ed.

Malrotation of gut

More Related Content

What's hot

Similar to Malrotation of gut

Recently uploaded

In this document

Malrotation of gut