Malrotation - SUNY Downstate Medical Centerdownstatesurgery.org/files/cases/malrotation_kate.pdf ·...

MalrotationMalrotation

Kate Sinnott, MDDepartment of Surgery

Downstate Medical CenterDownstate Medical Center8/20/2009

www.downstatesurgery.org

GI Causes of Vomiting in gInfant/Child

Bilious Nonbilious

Intussusception GastroenteritisIntussusception GastroenteritisMalrotation w/ volvulus GERDIncarcerated Hernia Hepatobiliary N t P titiNeonate PancreatitisHirschsprung’s GastroparesisNEC PUDCongenital Atresia AppendicitisMeconium Ileus Neonate

Pyloric StenosisPyloric Stenosis


Normal Gut Rotationwww.downstatesurgery.org

Normal Gut Roationwww.downstatesurgery.org

Normal Gut Rotationwww.downstatesurgery.org

Abnormal Gut RotationAbnormal Gut Rotation

• NonrotationNonrotation • When both limbs return to abdomen without furrther rotation• Small bowel on right and colon on left

Wid t l i k f l l• Wide mesentery – less risk of volvulus• Gastroschisis; Omphalocele; Diaphragmatic Hernia

• MalrotationMalrotation• Duodenojejunal limb remains in nonrotation in the right

midabdomenCecocolic limb in partial rotation in the midupper abdomen• Cecocolic limb in partial rotation in the midupper abdomen fixed to abdominal wall by Ladds bands


Abnormal Gut Rotationwww.downstatesurgery.org

Pathophysiology of MalrotationPathophysiology of Malrotation

• VolvulusVolvulus – Twisting of the small bowel about the

mesentery causing ischemiamesentery causing ischemia– Life threatening surgical emergency

• ObstructionL dd’ B d i th– Ladd’s Bands securing cecum cross the duodenum


P t ti f M l t tiPresentation of Malrotation

• 50% cases in infants less than 1month• 50% cases in infants less than 1month present with volvulus•10-15% cases in older children present with10 15% cases in older children present with volvulus•Symptoms of Obstruction

–vomiting; abdominal pain; distention•Symptoms of Volvulus –

iti (bili bili ) t–vomiting (bilious or nonbilious) most common symptom–Sepsis caused by bowel necrosisp y


Presentation of Malrotation in Older Children and Adults

•Variable and insidious•Intermittent abdominal pain/ vomiting•Failure to thriveFailure to thrive•Chronic diarrheaP titi•Pancreatitis

•Malabsorption


M l t tiMalrotation

XXray


UGIS Fi di i M l t tiUGIS Findings in Malrotation

•


B i EBarium Enema

•


CT S Fi di i M l t tiCT Scan Findings in Malrotation

•


S i l M t f M l t tiSurgical Management of Malrotation

L dd P dLadd Procedure–-goal is not to return bowel to normal

fi ticonfiguration–Prevent risk of volvulus

Wid h b f h–Widen the base of the mesentary–Placement of bowel in the position of

t ti ith ll b l i ht dnonrotation with small bowel on right and colon on leftAppendectomy-Appendectomy


L i L dd P dLaparoscopic Ladd Procedure

O l f d i th b f•Only performed in the absence of volvulus or bowel ischemia

•May be associated with higher y grecurrence rate due to fewer adhesions


Surgical Management of Incidental g gAsymptomatic Malrotation

C t i l•Controversial•Difficulty to determine width of mesentary and risk of volvulus by imaging •Most recommend laparocopic surgery for assessment of width of mesentary in yasymptomatic malrotation regardless of age or presenting symptomsg p g y p


R fReferences

1 Sabiston’s Te tbook of S rger To nsend1. Sabiston’s Textbook of Surgery. Townsend et al. Chapter 71

2 Up To Date Intestinal Malrotation Mary L2. Up To Date. Intestinal Malrotation. Mary L. Brandt. May 2009


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