Jack Barney Award. The changing spectrum of intestinal malrotation: diagnosis and management

Congenital anomalies of the gastrointestinal tract diagnosed in adulthood--diagnosis and management

INTRODUCTION

Congenital anomalies of the gastrointestinal tract are a significant cause of morbidity in children and less frequently in adults. In rare cases, they may run undetected during childhood and may present during adolescence. These abnormalities include developmental obstructive defects of the duodenum and the small intestine, anomalies of rotation and fixation, intestinal duplications, and anomalies of the colon and rectum.

DISCUSSION

When detected in adulthood, they may require different evaluation and surgical correction. Some of these anomalies should be managed surgically as soon as they cause symptoms. Others may cause persistent problems in adulthood requiring medical management for years. Herein, we present a comprehensive review of all the different ways of diagnosis and management of these anomalies reported in the literature.

Incidental chylous fluid during hernia repair may be a harbinger of malrotation

A previously asymptomatic 12-week-old male infant was found to have chylous ascites within his peritoneal hernia sacs during elective open bilateral inguinal hernia repair. Both repairs were completed, and an immediate postoperative upper gastrointestinal contrast study confirmed the presence of malrotation with associated volvulus. The patient underwent a Ladd's procedure and appendectomy. The postoperative course was uneventful. The finding of chylous ascites during hernia repair mandates investigation for possible malrotation.

Malrotation and midgut volvulus: a historical review and current controversies in diagnosis and management

The complex and sometimes controversial subject of malrotation and midgut volvulus is reviewed commencing with the 19th-century Bohemian anatomist, Václav Treitz, who described the suspensory muscle anchoring of the duodenal-jejunal junction in the left upper quadrant, and continuing with William Ladd, the 20th-century American "father of pediatric surgery" who pioneered the surgical treatment of midgut volvulus. In this review, we present the interesting history of malrotation and discuss the current radiologic and surgical controversies surrounding its diagnosis and treatment. In the symptomatic patient with malrotation and possible midgut volvulus, prompt diagnosis is critical. The clinical examination and plain film are often confusing, and delayed diagnosis can lead to significant morbidity and death. Despite recent intense interest in the position of the mesenteric vessels on US and CT scans, the upper gastrointestinal series remains the fastest and most accurate method of demonstrating duodenal obstruction, the position of the ligament of Treitz, and, if the contrast agent is followed distally, cecal malposition. Controversy exists over the management of asymptomatic patients with malrotation in whom the diagnosis is made incidentally during evaluation for nonspecific complaints, prior to reflux surgery, and in those with heterotaxy syndromes.