Malrotation, malnutrition, and ischemic bowel disease

Abstract

Ischemic bowel disease (IBD) is the common denominator in determining the mortality and morbidity in children with malrotation and volvulus. Survival in such patients depends on the degree of ischemic intestinal damage. In all patients there is another common factor, namely, host nutritional status. To evaluate host nutritional status in patients with malrotation and volvulus, we reviewed our recent 5-yr experience with 50 patients diagnosed as having malrotation, excluding those with gastroschisis, omphalocele, and diaphragmatic hernia. This review revealed two important clinical findings. First, volvulus was found to be the most frequent complication of the malrotation anomaly; and second, the nutritional status of the patient at operation was extremely poor in the majority of instances. Seventy percent of our patients were classified as having acute protein calorie malnutrition (PCM) by the criteria of McLaren and Read. Mild PCM was present in 28% while 42% had moderate to severe PCM. Three patients had volvulus with gangrene and all were severely malnourished. Thirteen of the 50 patients presented with failure to thrive (FTT). To further examine the relationship between IBD and PCM, we developed a mouse model of midgut ischemia. Normally nourished animals demonstrated an incidence of IBD of 1/60 (1.6%), 2/70 (2.9%), and 14/40 (35%) when made ischemic for intervals of 10, 15, and 20 min, respectively. The malnourished mice developed IBD at an incidence of 13/37 (36%), 32/49 (66%), and 30/40 (75%) after respective ischemic intervals of 10, 15, and 20 minutes (<i>p</i><0.01). These data would suggest that PCM enhances the development of IBD in this animal model. We speculate that children presenting with FTT should be evaluated for the presence of malrotation. Furthermore, children with malrotation have a significant incidence of PCM; and in the presence of vovulus, the associated PCM might predispose the child to irreversible ischemic bowel disease.