Presence Of Malrotation Research Articles

Delayed Presentation of Malrotation after Infancy: A Systematic Review Based on Clinical Presentations, Associated Anomalies, Diagnosis, and Management.

Approximately 75% of patients with classic malrotation and midgut volvulus present in neonatal age-group; another 15% may present up to one year. In these, the diagnosis is made because of typical presentation. However, there are many cases in which malrotation has been detected after infancy. In-spite of the variable case reports and studies in literature, there is no specific data on the incidence of malrotation after infancy, its presentation and management guidelines. With this systematic review, we aim to coalesce these findings from various individual case reports and studies. This systematic review was performed as per the PRISMA (preferred reporting items for systematic review and meta-analyses) guidelines. The authors conducted thorough searches in databases like PubMed/MEDLINE, SCOPUS, Google Scholar and Web of Science for relevant articles. Studies were reviewed for clinical presentation and outcome for malrotation diagnosed beyond infancy. Clinical presentation of malrotation after infancy can be acute as well as chronic; acute presentation being common under 2 years of age and chronic symptoms present as age increases. Sudden onset of abdominal pain and bilious vomiting are commonest acute symptoms and intermittent episodes of recurring vague abdominal pain associated with vomiting and diarrhoea are the commonest chronic symptoms. The diagnostic modalities vary from UGI Contrast series to USG with colour Doppler and CECT scan. Management is operative open as well as laparoscopic Ladd's procedure is being favoured.

Congenital Malrotation of the Midgut Presenting as Acute Duodenal Obstruction in a Teenager — A Case Report

Background: Intestinal malrotation, a congenital anomaly, typically presents in neonates with midgut volvulus. However, recent studies suggest it may occur in adolescents and adults at a higher rate than previously thought. This case report investigates the presentation and management of malrotation with volvulus in an adolescent. Case Presentation: A 14-year-old boy presented with acute onset abdominal pain, vomiting, and a history of intermittent abdominal pain for several years. Initial diagnosis was gastritis, but imaging revealed malrotation with volvulus. He underwent a successful Ladd's procedure. Conclusion: This case emphasizes that malrotation can present with chronic or acute symptoms in adolescents. A high index of suspicion for malrotation is crucial, particularly in adolescents with recurrent abdominal pain. Early diagnosis and Ladd's procedure can prevent life-threatening complications.

Delayed Presentation of Malrotation: Case Series and Literature Review.

Intestinal malrotation is a congenital anomaly resulting from abnormal or incomplete rotation and fixation of the midgut during embryogenesis. It commonly presents in the neonatal period (75%) with sudden onset bilious vomiting and rarely beyond infancy (<10%). The aim of the study was to highlight the clinical features, radiological findings, and treatment outcomes of patients with malrotation presenting beyond infancy. Eleven consecutive cases of delayed presentation of malrotation presented over a period of 5 years (2017-2021). Data were analyzed retrospectively. Out of the 11 patients, four were female and seven were male. The age of patients ranged from 14 months to 18 years. Patients beyond infancy present usually with diffuse pain abdomen compared to neonates which present with sudden onset bilious vomiting and therefore difficult to diagnose. Five patients had associated abnormalities such as intussusception or nutcracker syndrome or mesenteric cyst or jejunal stricture or mesenteric lymphadenopathy along with malrotation. Patients underwent ultrasonography, upper gastrointestinal contrast study, and contrast-enhanced computed tomography abdomen to confirm the diagnosis. All patients underwent the Ladd procedure with four requiring resection anastomosis and one requiring excision of the mesenteric cyst. Eight out of eleven patients had favorable outcomes, two develop adhesive intestinal obstruction and required re-exploration, and one had persistent complaints of hematochezia. Malrotation beyond infancy is a rare diagnosis. Malrotation in older children is usually not suspected because of the wide range of symptoms. A high index of suspicion on ultrasound or computed tomography is required to demonstrate the reversal of superior mesenteric artery and superior mesenteric vein position and related conditions. Early intervention and treatment can prevent catastrophic events such as intestinal volvulus and intestinal ischemia in these patients.

Late presentation of midgut malrotation with obstruction in a child

Midgut malrotation is an anomaly of intestinal rotation that occurs during embryology and usually presents during neonatal period. Symptoms are vague as presentation is delayed whilst some can be identified incidentally during adulthood. Herein we report of a 6-year-old girl who presented with food intolerance, abdominal pain and failure to gain weight. CT-scan confirmed midgut malrotation and was successfully managed by open Ladd's procedure. • Midgut malrotation is a congenital anomaly that usually presents in the neonatal period. • Symptoms are unspecific in older children and sometimes asymptomatic in others. • Midgut malrotation has a high risk of bowel ischaemia due to compression of the SMA. • CT-scan with contrast is diagnostic tool of choice and shows “whirlpool” sign. • Mainstay management is surgery (Ladd's procedure) with promising outcome.

Sagittal femoral bowing contributes to distal femoral valgus angle deviation in malrotated preoperative radiographs

BackgroundThe coronal whole-leg radiograph is generally used for preoperative planning in total knee arthroplasty. The distal femoral valgus angle (DFVA) is measured for distal femoral bone resection using an intramedullary guide rod. The effect of coronal and sagittal femoral shaft bowing on DFVA measurement in the presence of malrotation or knee flexion contracture has not been well reported. The objectives of this study were: (1) to investigate the effects of whole-leg malrotation and knee flexion contracture on the DFVA in detail, (2) to determine the additional effect of coronal or sagittal femoral shaft bowing.MethodsWe studied 100 consecutive varus and 100 valgus knees that underwent total or unicompartmental knee arthroplasty. Preoperative CT scans were used to create digitally reconstructed radiography (DRR) images in neutral rotation (NR, parallel to the surgical epicondylar axis), and at 5° and 10° external rotation (ER) and internal rotation (IR). The images were also reconstructed at 10° femoral flexion. The DFVA was evaluated in each DRR image, and the angular variation due to lower limb malposition was investigated.ResultsThe DFVA increased as the DRR image shifted from IR to ER, and all angles increased further from extension to 10° flexion. The DFVA variation in each position was 1.3° on average. A larger variation than 2° was seen in 12% of all. Multivariate regression analysis showed that sagittal femoral shaft bowing was independently associated with a large variation of DFVA. Receiver operating characteristic analysis showed that more than 12° of sagittal bowing caused the variation.ConclusionIf femoral sagittal bowing is more than 12°, close attention should be paid to the lower limb position when taking whole-leg radiographs. Preoperative planning with whole-leg CT data should be considered.

Intestinal malrotation with multiple congenital anomalies

Intestinal malrotation (IM) occurs secondary to abnormal midgut rotations. It is a common and often devastating cause of neonatal bowel obstruction. Associated anomalies in IM is high, up to 60%. We present a case malrotation without volvulus in a day 8 of life neonate associated with duodenal atresia (fenestrate web), annular pancreas, polysplenia, preduodenal portal vein and anorectal malformation (rectoperineal fistula). This case offered a unique presentation of malrotation with multiple anomalies, and highlights need of high index of suspicion of additional congenital anomalies when managing malrotation.

Case Series of Acute Abdomen with Midgut Malrotation Presenting in Adulthood

Introduction: Intestinal malrotation (IM) is a congenital anomaly due to partial or complete failure of the 270° counter-clockwise rotation of the midgut around the superior mesenteric vessels in 5th to 12th week of fetal life. Midgut malrotation usually presents as an emergency in the 1st month of life or within infancy. Adult cases are rarely reported and usually present with chronic nonspecific symptoms. Here, we present a case series of acute abdomen with midgut malrotation presenting in adulthood that came to the Department of Surgical Gastroenterology of a tertiary hospital in Salem, Tamil Nadu. Case Summary: Four patients presented with acute abdominal complaints, diagnosed, and proceeded with emergency laparotomy. Three patients had abdominal abnormalities unrelated to coexisting IM, and the other one showed sequelae of IM with Ladd's band and obstruction. Except the first patient, all other patients improved well postoperatively and were discharged without complications. Conclusion: IM should be considered in differential diagnosis of acute abdomen and bowel obstruction in adults. IM may be encountered as an incidental imaging/laparotomy finding or be the cause of acute abdomen.

Colon cancer in malrotated gut: A case report

Malrotation of the gut is a rare congenital anomaly that mostly presents in the 1st month of life. Very rarely, it is found during adulthood either as an asymptomatic incidental finding or at autopsy. Presenting in adulthood with colon cancers is extremely rare. Here, we present the case of a middle-aged male patient with unexplained anemia which on investigation was found to have adenocarcinoma at the hepatic flexure of the colon. The staging computed tomography scan of the abdomen showed the growth at the hepatic flexure with malrotation of the gut. During the laparoscopic assessment, the cecum and ascending colon were found on the left side, and hence, a formal midline incision was made. Cecum was found on the left of the midline along with Ladd’s band. Extended right hemicolectomy was performed, dividing the Ladd’s band, taking care of the anomalous position of superior mesenteric vessels. The post-operative period was uneventful. Histopathological examination revealed this to be well-differentiated adenocarcinoma (pT3N1b). He thereafter received adjuvant chemotherapy and remains well after 5 years of follow-up. Presentation of malrotation of the gut in adulthood is seen in only 10–15% of cases as an incidental finding or at autopsy. Cancers in the colon in these patients are extremely rare. The treatment for colon cancer remains the same although one has to be careful about the vascular anomaly during the resection.

Pain Abdomen as a Presentation of Congenital Malrotation of Gut: A Case Series

Malrotation of the gut can present at any age but the majority of patients present in neonatal period or early infancy. Most children present with a history of recurrent colicky abdominal pain, vomiting which can be bilious and failure to thrive. Delay in diagnosis leads to increase in mortality and morbidity. Here we present a series of three patients, one girl aged 6 years, one 10 months old boy and one 10 years old boy, who got admitted at our Pediatric Department in a one month period. Patients had a history of recurrent abdominal pain and occasional vomiting, seen and managed by multiple paediatricians and GP doctors with extensive diagnostic workup but never the accurate diagnosis was made. Thorough history was taken and examination done, planned work up done for diagnosis. High index of suspicion is needed in children presenting with recurrent pain in the abdomen. Targeted work-up should be done and patients be kept on follow-up for diagnosis of late presentation of congenital malrotation of the gut.

S1625 Rare Case of Congenital Midgut and Pancreas Malrotation Presenting as Pancreatitis at Older Age

S1625 Rare Case of Congenital Midgut and Pancreas Malrotation Presenting as Pancreatitis at Older Age

A Comprehensive Review of Intestinal Atresias

A Comprehensive Review of Intestinal Atresias

INTESTINAL MALROTATION - A COMMON YET DEADLY CAUSE OF NEONATAL SMALL BOWEL OBSTRUCTION

Background: This study was done at SMS Medical College, Jaipur with an aim of emphasizing the need of having a high index of suspicion in newborn presenting with bilious vomiting for the diagnosis of malrotation. Methods: Cases of neonatal small intestinal obstruction due to malrotation presenting to the Department of Paediatric Surgery, SMS Medical College, Jaipur over a period of two years were evaluated. Results: A total of 48 newborns presented to our department with intestinal obstruction due to malrotation. Majority (82%) of the patients presented in the 2nd and 3rd week of life. 6 out of 48 patients presented with extensive gangrene of midgut. 9/48 patients died during the course of treatment and during follow-up. Conclusion: Malrotation is a relatively common cause of neonatal small bowel obstruction. A high index of suspicion is required in neonates presenting with bilious vomiting. Prompt diagnostic tools and early laparotomy prevents fatal complication of extensive midgut gangrene due to volvulus.

Intestinal malrotation in adults: prevalence and findings based on CT colonography.

Intestinal malrotation is largely a pediatric diagnosis, but initial detection can be made in adulthood. CT colonography (CTC) provides an ideal means for estimating prevalence. Our purpose was to evaluate the prevalence and imaging findings of intestinal malrotation in asymptomatic adults at CTC screening, as well as incomplete optical colonoscopy (OC) referral. The CTC database of a single academic institution was searched for cases of intestinal malrotation (developmental nonrotation). Prevalence was estimated from 11,176 adults undergoing CTC. Demographic, clinical, imaging (CTC and other abdominal exams), and surgical data were reviewed. 27 cases of malrotation were confirmed (mean age 62 ± 9years; 15M/12F), including 17 from the CTC screening cohort (0.17% prevalence) and 10 from incomplete OC (0.75% prevalence; p < 0.001). Most cases (59%; 16/27) were initially diagnosed at CTC. In 67% (12/18); the presence of malrotation was missed on at least one relevant abdominal imaging examination. At least 22% (6/27) had a history of unexplained, chronic intermittent abdominal pain. At CTC, the SMA-SMV relationship was normal in only 11% (3/27). The ileocecal valve was located in the RLQ in only 22% (6/27). Two patients (7%) had associated findings of heterotaxy (polysplenia). The prevalence of intestinal malrotation was four times greater for patients referred from incomplete OC compared with primary screening CTC, likely related to anatomic challenges at endoscopy. Malrotation was frequently missed at other abdominal imaging examinations. CTC can uncover unexpected cases of malrotation in adults, which may be relevant in terms of potential for future complications.

Congenital Midgut Malrotation Presenting as Acute Duodenal Obstruction in an Adult—Laparoscopic Management

Congenital Midgut Malrotation Presenting as Acute Duodenal Obstruction in an Adult—Laparoscopic Management

A rare presentation of midgut malrotation as an acute intestinal obstruction and perforation in an adult

Midgut malrotation is a congenital anomaly seen usually in childhood. Its presentation as an acute intestinal obstruction is extremely rare in adults usually identified intra operatively. A high index of suspicion is always required when dealing with any case of acute intestinal obstruction. We report a case of young adult who presented with symptoms of acute intestinal obstruction and was diagnosed intra-operatively as cecal volvulus with impending perforation caused by midgut malrotation. Malrotation of the intestinal tract is seen due to aberrant embryology. The presentation of intestinal malrotation in adults is very rare. Contrast enhanced Computed tomography (CT) can show the abnormal anatomy clearly. Anomalies like midgut malrotation can present as an operative dilemma and awareness regarding these conditions can help surgeons deal with these conditions.

Rare presentation of congenital gut malrotation as adult cecal volvulus

Incomplete or faulty rotation and fixation of the gut during 5th–11th week of the fetal life results in intestinal malrotation. Cecal volvulus is a rare (1%–1.5%) cause of intestinal obstructions in adults. However, it accounts up to 25%–40% of all volvuluses involving the colon. Cecal volvulus due to malrotation presenting as an intestinal obstruction in an adult is very rare, and only few cases are reported in the literature. We present a case report of a 33-year-old adult male who presented to the emergency with a 2-day history of pain abdomen and vomiting with no significant past history. Per abdomen examination revealed a tender lump in the right paraumblical region. The diagnosis of intestinal obstruction was made on clinical and X-ray features. Emergency laparotomy was done. However, to our surprise, we found that the patient is having malrotated gut with cecal volvulus with the features of intestinal obstruction. The cecal volvulus was carefully de-torted, and right hemicolectomy with hand-sewn end-to-side ileotransverse anastomosis was done. Postoperatively, the patient behaved well and was discharged on the 8th postoperative day.

Malrotation presenting beyond infancy: a clinical study

Background: Intestinal malrotation is a congenital anomaly that results from abnormal or incomplete rotation and fixation of midgut during embryonic development. This study was done at Niloufer Hospital and Institute for Women and Child Health, Hyderabad with an aim of evaluating the clinical presentation, diagnosis, management and outcome of malrotation presenting beyond 1 year of lifeMethods: Overall 50 cases of malrotation presented to the department of pediatric surgery over a period of 2 year (April 2015 to April 2017). 12 patients of these 50 (12/50) whose age was above 1 year i.e. who were beyond infancy were studied in this studyResults: Out of the 12 patients, 6 were female and 6 were male. Age of patients ranged from 15 months to 13 years. Younger patients below 2 years commonly presented with typical symptoms of bilious vomiting and patients above 2 years of age presented with more varied and vague symptoms. 1/12 of patients presented with a poor general condition and succumbed during the course of treatmentConclusion: Small intestinal obstruction due to malrotation is relatively common in neonatal period. Malrotation beyond infancy is an uncommon diagnosis. Malrotation in grown up children usually is not suspected due to varied symptoms. High index of suspicion is needed as early intervention and treatment in the form of Ladds procedure can prevent any catastrophic events like volvulus and bowel ischemia.

A case of midgut malrotation presenting as subacute intestinal obstruction in an adult

A case of midgut malrotation presenting as subacute intestinal obstruction in an adult

Malrotation is not associated with adverse outcomes after cardiac surgery in patients with heterotaxy syndrome

BackgroundPatients with heterotaxy syndrome (HS) often have asymptomatic malrotation. There is a lack of consensus regarding the management of these patients, particularly in patients with complex congenital heart disease (CHD). We sought to describe the prevalence of malrotation and incidence of volvulus in a population of patients with complex CHD and to identify the impact of malrotation on morbidity and mortality following cardiac surgery. MethodsWe performed a retrospective review of all patients with HS and complex CHD who required cardiac surgery in the first year of life at a single center between October 1995 and September 2015. Malrotation was diagnosed by abdominal imaging or by direct inspection during abdominal surgery. Demographic data was collected along with details of hospitalization following cardiac and GI surgeries. Descriptive analysis along with appropriate hypothesis testing was conducted to evaluate the results. ResultsWe identified 49 patients with HS, 42 with single ventricle anatomy and 7 with biventricular anatomy. Of the 49 patients, 29 (59%) were diagnosed with malrotation, 6 (12%) had normal intestinal rotation, and 14 (29%) had no evaluation of intestinal rotation. The prevalence of malrotation in the population who underwent abdominal imaging was 29 out of 35 (83%). There was no difference in survival following cardiac surgery between patients with malrotation and those with unknown or normal intestinal anatomy. Comparing patients with malrotation and patients with normal or unknown intestinal rotation, there was also no difference in surrogate markers of morbidity. Of the 29 patients with known malrotation, only 2 patients (7%) underwent therapeutic Ladd procedures and 19 (65%) underwent prophylactic Ladd procedures. ConclusionsWe conclude that the outcomes following cardiac surgery for patients with HS are not impacted by the presence of malrotation. Furthermore, we also found that the incidence of volvulus in the studied group is low. Given these findings, and the understanding that patients with HS and significant CHD are frequently tenuous and high risk surgical candidates, we do not believe performing prophylactic Ladd procedures is warranted. Level of evidenceIII.

Postpartum Abdominal Pain, With a Twist

Introduction: Intestinal malrotation classically presents in the neonatal period as acute obstruction due to intestinal, or midgut, volvulus. Midgut volvulus due to intestinal malrotation is rare in adults, with an estimated incidence of 0.2-0.6%. We present a case of a young, post-partum woman who presented with two months of abdominal pain and was found to have a midgut volvulus from intestinal malrotation. To our knowledge, this is one of the first cases of intestinal malrotation presenting as midgut volvulus after uterine involution. Case Report: A 22-year-old female with no history presented with progressively worsening post-prandial epigastric pain that started after she gave birth 2 months prior. She had an uncomplicated pregnancy and normal vaginal delivery. Over the past week, the pain had became more severe and persistent, and was accompanied by nausea and bilious vomiting. She denied weight loss and had no other constitutional symptoms. She did note constipation over the past few days but was still passing flatus. Exam revealed tenderness to palpation over the epigastrium without evidence of an acute abdomen. Labs were significant for a blood urea nitrogen of 33, hemoglobin of 16.3, and hematocrit of 50. Hepatic function panel revealed an elevated total bilirubin level of 3.5. A RUQ ultrasound done to rule out biliary obstruction showed a twisting of the proximal superior mesenteric artery (SMA) and vein (SMV) with patent flow. A CT angiography of the abdomen and pelvis showed the classic “whirlpool sign,: confirming a midgut volvulus with intestinal malrotation, with resultant duodenal obstruction. There was no evidence of bowel ischemia or perforation. An emergent surgical consultation was placed and the patient was taken down for an exploratory laparotomy with detorsion of volvulus, lysis of Ladd's bands, broadening of the mesentery, and an appendectomy.Figure: Sonographic evidence of SMV and SMA twisting.Figure: Classic “whirlpool” sign seen on CT angiography of abdomen/pelvis.Figure: Anatomic deviation of congenital malrotation; appendix seen in left upper quadrant.Discussion: Total small intestinal volvulus with malrotation classically (64-80% of the time) presents in neonates, typically within the first month of life. Symptomatic intestinal malrotation is rare in adults. This is often an incidental finding, although symptoms can range from those associated with obstruction or reflux to those found in acute intestinal infarction. CT findings can be pathognomonic if the whirlpool sign is seen. CT also allows for rapid diagnosis and surgical treatment, which is important as delayed diagnosis or treatment can result in bowel necrosis and death.