Volvulus, prolapse, intussusception, and functional. It is particularly important to recognize intestinal malrotation and midgut volvulus as mimics of the doublebubble sign. Liver hematoma presented as midgut volvulus due to medical. Primary midgut volvulus is a term used when there is no underlying cause for the volvulus. This condition, known as midgut volvulus, may cause intermittent abdominal distention and pain or acute bowel necrosis. In light of this finding, we obtained a computed tomography ct scan. Malrotation american pediatric surgical association. Malrotation is in itself harmless, and an infant can have malrotation without a volvulus. Midgut malrotation commonly presents in the neonatal period, and rarely manifests its symptoms in adulthood with an estimated incidence of 0. However, as the use of ct in emergency departments increases, midgut volvulus is increasingly being recognized in adults. The most common clinical presentation of midgut volvulus is bilious vomiting, which is a nonspecific sign of intestinal obstruction.
Volvulus of the cecum, transverse colon, or sigmoid colon occurs, usually in adults, with only minor predisposing factors such. Nevertheless, the symptoms are nonspecific with no strong pointers towards the clinical diagnosis. Pdf thirty four neonates presented with acute duodenal obstruction due to malrotation during a 9 year period between 1973 and the end of 1981. Volvulus causes pain in the abdomen, nausea, vomiting, and blood in stools. Portal venous gas in intestinal malrotation with mild. An adult presentation of midgut volvulus secondary to intestinal.
Disorders of intestinal rotation and fixation are of paramount impor. Segmental volvulus occurs in people of any age, usually with a predisposition because of abnormal intestinal contents e. Endoscopic management of a pregnant lady with duodenal. In the second sister, the volvulus probably occurred at an earlier gestational age, causing intestinal atresia. Volvulus can develop in any part of the gastrointestinal tract including stomach, small intestine, cecum, and sigmoid colon. At the fourth week of gestation, the gi system is a straight tube centrally located in the abdomen. To identify risk factors for midgut volvulus mgv and to seek clues to early diagnosis of mgv in children with malrotation. Midgut volvulus occurs in people usually babies that are predisposed because of. Primary midgut volvulus in a patient with marfan syndrome.
The gut is therefore prone to twist counterclockwise around the superior mesenteric artery and vein. One had gangrene of the entire small intestine, suggesting that the intestinal volvulus was late in onset. Midgut volvulus midgut volvulus is a different clinical entity and is most common in children. The surgery done for midgut volvulus is called as a ladds procedure and is the preferred choice of treatment for midgut volvulus. However, the true incidence is difficult to determine as a substantial number of. Midgut malrotation with congenital peritoneal band. Midgut malrotation refers to twisting of the entire midgut about the axis of the superior mesenteric artery sma. Intestinal volvulus is a broad term that describes the torsion of bowel around its mesentery. A brief overview of the rotation of the midgut during development. In children it rarely rises in mesentery or gastrointestinal tract and the secondary midgut volvulus caused by lipoma is very rare1,2. A midgut volvulus of malrotated bowel can potentially occur at any age but in approximately 75% of cases occur within a month of birth 4,6. Malrotation of the intestine occurs when the normal embryologic sequence of bowel development and fixation is interrupted. It may result in proximal bowel obstruction with resultant ischemia if prompt treatment is not instigated.
Volvulus of the small bowel is more common in children and is most often secondary to malrotation. Ugi duodenal bulb volvulus corkscrew duodenum with corkscrew appearance in intestinal malrotation contrast study in duodenal atresia barium enema intestinal malrotation barium enema image of transverse colon cutoff due to midgut vol ileus plain radiograph of an infant with duodenal atresia ct whirlpool sign of midgut volvulus plain radiographs necrotizing. Midgut volvulus occurs in people usually babies that are predisposed because of congenital intestinal malrotation. Contrastenhanced ct, performed 1 h later from echography, revealed a whirlpool sign suggesting an intestinal malrotation with midgut volvulus, but with no signs of residual intrahepatic gas. In patients with surgically confirmed midgut volvulus, color doppler ultrasound showed clockwise whirlpool sign in 12 patients and no whirlpool sign in one patient. Chronic midgut volvulus with mesenteric lymphangioma. A volvulus is when a loop of intestine twists around itself and the mesentery that supports it. Endoscopic management of a pregnant lady with duodenal obstruction due to malrotation with midgut volvulus. The midgut is the portion of the embryo from which most of the intestines develop. Midgut volvulus secondary to intestinal malrotation is a rare cause of an acute abdomen in adults, with 92 confirmed cases in the literature. Postoperative diagnosis was abdominal wall hematoma and rand ligament and ileus, as well as, subcapsular liver hematoma. This scan identified multiple dilated loops of small bowel, consistent with small bowel obstruction figure 3, and twisting of the smallbowel mesentery around the axis of the superior mesenteric artery sma in a classic whirl sign consistent with midgut volvulus figure 4.
Malrotation and volvulus due to the risk for loss of bowel, any infant with bilious emesis must be evaluated for malrotation and volvulus. Midgut malrotation first presenting as acute bowel. The clinical manifestations, diagnosis, and treatment of intestinal malrotation in. If the volvulus is missed, it can lead to vascular compromise, which can cause intraluminal bleeding evidenced by melena andor hematemesis and worsening intestinal ischemia can lead to signs of shock. Malrotation with midgut volvulus can be a catastrophic event resulting in intestinal ischemia and shock, and it represents a surgical emergency in the neonate. It has been estimated that it affects approximately 1 in 500 live births. Stalker and chitayat 1992 described 2 sisters with congenital midgut volvulus. Midgut volvulus presenting with acute chylous peritonitis is known in children, but is extremely rare in adults.
Intrauterine midgut volvulus has occasionally been associated with delayed return of the fetal midgut to the abdomen 3, segmental or basal mesenteric defects 4, fibrous enteroumbilical band 5 and segmental defect of the smooth muscle of the bowel 6. If there is malrotation at the time of fetal development then it can make that baby vulnerable to having volvulus. Neonatal malrotation with midgut volvulus mimicking. Midgut volvulus is a complication of malrotated bowel. In group b, the preoperative diagnosis included necrotizing enterocolitis and midgut volvulus. However, because having malrotation places the infant at an increased risk for a midgut volvulus.
Herein, we report a 6yearold girl with small bowel lipoma causing midgut volvulus. Iranian journal of pediatrics midgut volvulus caused by. Created by ali nabavizadeh for the university of chicago pritzker school of medicine anato. Volvulus in a neonate or infant almost always presents as a midgut volvulus secondary to intestinal malrotation. Operative findings showed a mild volvulus with neither congestion nor ischemic change of the twisted bowel. Midgut malrotation is a congenital anomaly in the embryological development of the foetal intestinal rotation. History and clinical examination a 10 yr old female patient comes to casualty with complaints of pain in epigastric region which was acute in onset since 24 days bilious vomiting since 24 days a lump was felt in the epigastrium with localised tenderness temperature was slightly raised rest parameters were within normal limits.
Midgut volvulus rotation of the entire bowel from the second portion of the duodenum to the mid. Frontiers primary segmental volvulus of small intestine. In both groups, the site of volvulus was most commonly the distal small intestine ileum, 81. Pdf the surgery of malrotation and midgut volvulus. Kenney introduction malrotation is a spectrum of anatomic abnormalities of incomplete rotation and fixation of the intestinal tract during foetal development.
During the surgery, no intestinal malrotation, mesenteric defect or atresia was observed. In conclusion, we present a rare case of malrotation with midgut volvulus in an adult. Volvulus is defined as the twisting of a loop of bowel on its mesentery and is one of the most common causes of intestinal obstruction. Meconiumrelated ileus, hirschsprungs disease were also suspected. Infants with malrotation and midgut volvulus often are described as having bilestained emesis, abdominal distention, and peritoneal signs and may appear ill. Chapter 65 intestinal malrotation and midgut volvulus.
Because of its rarity, the diagnosis of intestinal malrotation in adult patients is often delayed and therefore associated with increased morbidity. In order for a vessel to be compressed and obstructed, the force that the torsion imparts on the vessel needs to be greater. It comprises the portion of the alimentary canal from the end of the foregut at the opening of the bile duct to the hindgut, about twothirds of the way through the transverse colon. Midgut volvulus can be primary without findings of any associated underlying cause, or secondary to other congenital or acquired conditions. Primary midgut volvulus is more frequent in children and young adults and rarely presents in adults, among whom secondary volvulus is. The most severe complication of malrotation is midgut volvulus, in which the mesenteric base twists around the superior mesenteric artery, compromising intestinal. Torsion results in narrowing of the lumen at the point of rotation and compromise of the vessels that supply the torted gut. We present a case of volvulus without malrotation in a twin fetus where serial antenatal us assisted in the diagnosis and ensured prompt postnatal surgical treatment. History and clinical examination a 10 yr old female patient comes to casualty with complaints of pain in epigastric region which was acute in onset since 24 days bilious vomiting since 24 days a lump was felt in the epigastrium with localised tenderness temperature was slightly raised rest parameters were within. Initially, diagnosis was midgut volvulus, for which an operation was performed. The sensitivity, specificity, and positive predictive value of clockwise whirlpool sign for midgut volvulus. Consequently, the diagnosis is usually disclosed with imaging or surgery. After it bends around the superior mesenteric artery, it is called the midgut loop.
Us demonstrated a reversal of the normal relationship between the. By this method, the midgut volvulus is corrected by rotating the small intestine in anticlockwise manner with the cecum located on the left of abdomen and the duodenum down the right paravertebral gutter. We report a case of small bowel obstruction secondary to a. Given his acute presentation, operative intervention was the natural trajectory in his management. The sigmoid colon, and less frequently, the cecum, are the common sites of volvulus in adults.
This case describes an 80yearold female with marfan syndrome presenting with primary midgut volvulus, which preoperatively was suspected based on imaging, and. Strangulated intestinal obstruction mechanical obstruction. Pdf chronic midgut volvulus with mesenteric lymphangioma. A knowledge of embryology is necessary to understand the mechanisms that lead to the development of volvulus and malrotation. Small bowel volvulus is an uncommon cause for small bowel obstruction in adults, and is more likely to be secondary to postoperative adhesive bands. Presentation varies but most severe type is with midgut volvulus which is due to twisting of the abnormally fixated small bowel around a narrow. The best diagnostic choice to diagnose malrotation, with or without midgut volvulus, is an upper gi series.314 1458 1320 1121 1456 1331 590 510 751 1419 1114 831 33 461 1085 155 1003 1422 898 14 1214 250 1456 51 1193 147 1403 731 1313 238 394 767 1135 323 783 1476 374 133 975 15