SciCombinator

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Concept: Intestinal malrotation

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Midgut malrotation is an anomaly of intestinal rotation that occurs during fetal development and usually presents in the neonatal period. We present a rare case of malrotation in a 14-year-old patient who presented with cramping, generalized right abdominal pain, and vomiting for a duration of one day. A computed tomography abdominal scan and upper gastrointestinal contrast studies showed malrotation of the small bowel without volvulus. Laparoscopy revealed typical Ladd’s bands and a distended flabby third and fourth duodenal portion extrinsically obstructing the misplaced duodeno-jejunal junction. The Ladd procedure, including widening of the mesenteric base and appendectomy, was performed. Symptoms completely resolved in a half-year follow up period. Patients with midgut malrotation may present with vague abdominal pain, intestinal obstruction, or intestinal ischemia. The laparoscopic Ladd procedure is feasible and safe, and it appears to be as effective as the standard open Ladd procedure in the diagnosis and treatment of teenage or adult patients with intestinal malrotation.

Concepts: Abdominal pain, Small intestine, Bowel obstruction, Abdomen, Jejunum, Volvulus, Intestinal malrotation, Ladd's bands

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Background/Purpose Malrotation with a common mesentery is the classical pathology allowing midgut volvulus to occur. There are only a few reports of small bowel volvulus without malrotation or other pathology triggering volvulation. We describe three cases of small bowel volvulus in very premature newborns with a perfectly normal intra-abdominal anatomy and focus on the question, what might have set off volvulation.Methods In 2005 to 2008, three patients developed small bowel voluvulus without any underlying pathology. Retrospective patient chart review was performed with special focus on clinical presentation, preoperative management, intraoperative findings, and potential causative explanations. Mean follow-up period was 46 months.Results All patients were born between 27 and 31 weeks (mean 28 weeks) with a birth weight between 800 and 1,000 g (mean 887 g). They presented with an almost identical pattern of symptoms including sudden abdominal distension, abdominal tenderness, erythema of the abdominal wall, high gastric residuals, and radiographic signs of ileus. All of them were treated with intensive abdominal massage or pelvic rotation to improve bowel movement before becoming symptomatic.Conclusions Properistaltic maneuvers including abdominal massage and pelvic rotation may cause what we term a “manufactured” volvulus in very premature newborns. Thus, this practice was stopped.

Concepts: Digestive system, Abdominal pain, Small intestine, Bowel obstruction, Peritoneum, Abdomen, Volvulus, Intestinal malrotation

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Intestinal malrotation displays classic pattern of the small bowel activity on hepatobiliary scintigraphy that could lead to the diagnosis, but only if an interpreting physician looks for it. Presented are 2 cases, one demonstrates diagnostic findings during the first 60-minute phase, whereas the other reveals the diagnosis only on the later sincalide stimulation phase. The currently recommended structured reporting for hepatobiliary scintigraphy does not include examination of bowel activity pattern, which could result in a missed diagnosis. Including interrogation of the small bowel pattern into the structured reporting checklist would ensure consistent detection of this rare but most consequential diagnosis.

Concepts: Diagnosis, Surgery, Large intestine, Intestine, Small intestine, Case, Intestinal malrotation, Lacteal

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Intestinal malrotation places pediatric patients at the risk of midgut volvulus, a complication that can lead to ischemic bowel, short gut syndrome, and even death. Even though the treatments for symptomatic patients of this complication are clear, it is still a challenge to identify asymptomatic patients who are at a higher risk of midgut volvulus and decide on a suitable course of treatment. Development of an accurate computerized model of this intestinal abnormality could help in gaining a better understanding of its integral behavior. To aid in developing such a model, in the current study, we have characterized the biaxial mechanical properties of the porcine small bowel mesentery. First, the tissue stress-strain response was determined using a biaxial tensile testing equipment. The stress-strain data were then fitted into a Fung-type phenomenological constitutive model to quantify the tissue material parameters. The stress-strain responses were highly nonlinear, showing more compliance at the lower strains following by a rapid transition into a stiffer response at higher strains. The tissue was anisotropic and showed more stiffness in the radial direction. The data fitted the Fung-type constitutive model with an average R-squared value of 0.93. An averaging scheme was used to produce a set of material parameters which can represent the generic mechanical behavior of the tissue in the models.

Concepts: Abdominal pain, Large intestine, Intestine, Small intestine, Bowel obstruction, Jejunum, Volvulus, Intestinal malrotation

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Waugh’s syndrome (WS) is the rare association of intussusception and intestinal malrotation. We present two such cases in a 5-month-old infant and a 9-year-old girl. Both patients presented with intussusception and were diagnosed with malrotation during workup and surgical exploration. We conclude that the possibility of intestinal malrotation must be taken into consideration while managing children with intussusception.

Concepts: Surgery, Intestinal malrotation

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Various reconstructions of the gastro-intestinal tract have been described in the past after distal gastrectomy. Among these, a Billroth II (BII) anastomosis can be performed with the addition of the Omega entero-enterostomy that may theoretically reduce the alkaline reflux. Given the significant complications associated with this procedure such as biliary reflux, marginal ulceration, and afferent loop syndrome, a revision into a Roux-en-Y anatomy is generally recommended.

Concepts: Surgery, Digestive system, Gastroenterology, Intestinal malrotation

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It is difficult to differentiate between the potential adverse effects of general anesthesia (GA) on the developing brain and the role of associated co-morbidities and syndromes that can adversely affect neurodevelopmental outcomes in neonates undergoing GA. Neonates with malrotation of the intestines without volvulus usually do not have co-morbidities or syndromes. In addition, majority of them recover very well after surgery and are discharged home within a few days. Neonates with malrotation are a clean cohort of babies to study the role of a single episode of GA on the developing brain.

Concepts: Infant, Surgery, Affect, Anesthesia, Adverse drug reaction, Volvulus, Intestinal malrotation

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We report a case of gastroschisis in male twins. Both twins were preterm and low birth weight, with intestinal malrotation; they were diagnosed by antenatal ultrasound at 20 weeks of gestation. Immediately after delivery, they underwent evaluation and early surgical one-stage repair under anesthesia. One of the twins was found to have duodenal perforation at laparotomy, at the horizontal part near Treitz ligament. Both twins stayed in hospital for 30 days and were in good health at discharge.

Concepts: Childbirth, Human, Reproduction, Surgery, Obstetrics, Al-Andalus, Twin, Intestinal malrotation

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Here we report the case of a pregnant 28-year-old who presented with acute upper abdominal pain. CT demonstrated midgut volvulus with short segment occlusion of the superior mesenteric artery (SMA). Emergent detorsion of the small bowel was performed, at which time underlying intestinal malrotation was discovered. Following detorsion, the SMA had a bounding pulse and did not require thrombectomy or revascularization. Fewer than 25 cases of midgut volvulus during pregnancy have been reported over the past 20years. To our knowledge, this is the first report of maternal midgut volvulus in which imaging captures the resultant occlusion of the SMA.

Concepts: Abdominal pain, Large intestine, Small intestine, Bowel obstruction, Superior mesenteric artery, Volvulus, Intestinal malrotation, Superior mesenteric artery syndrome

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Malrotation with midgut volvulus is a common surgical emergency in children. A diagnostic tool for malrotation with characteristics ideal in emergency settings such as non-invasiveness and rapidity remains a keenly debated issue among surgeons and radiologists alike.

Concepts: Diagnosis, Hospital, Surgery, American College of Surgeons, Volvulus, Intestinal malrotation