Malrotation of the intestine

A rare case of extensive pneumatosis cystoides intestinalis with intestinal malrotation: Case report

Intramural bowel gas (Pneumatosis intestinalis) refers to the radiological or clinical evidence of gas within the wall of the bowel lumen. While intramural gas could be secondary to life-threatening pathologies such as mesenteric ischemia in adults and necrotizing enterocolitis in neonates, it could also occur as a rare benign sub-type called Pneumatosis cystoides intestinalis, which is characterized by multiple gas-filled cysts in the submucosa and/or subserosal of the gastrointestinal tract. Distinguishing between life-threatening Pneumatosis intestinalis and its benign subtypes requires careful clinical and imaging evaluation. This involves identifying additional findings that could indicate potentially concerning causes of Pneumatosis intestinalis. Recognizing these signs is essential for effectively managing the patient because conservative management is preferred for Pneumatosis cystoides intestinalis. In this case study, we describe a patient presenting to our hospital with chronic intermittent abdominal pain persisting for about 2 years, accompanied by episodic vomiting. An abdominal CT scan revealed the presence of multiple air-filled cysts within the wall of the mal-rotated cecal bowel loop, which is abnormally located in the right upper quadrant. Associated with this pneumoperitoneum is seen in the peritoneal cavity. No other significant findings were observed on the scan. To our knowledge, this is the first case of pneumatosis cystoid interstinalis occurring in a mal-rotated gut. We also delve into the potential etiologies and management strategies for Pneumatosis cystoides intestinalis, as well as differentiating signs from the life-threatening intramural gas variant.

Left side appendiceal abscess in a patient with intestinal nonrotation: Case report

Intestinal nonrotation is the most common type of mid-gut anomaly where the small bowel predominantly occupies the right side of the peritoneal cavity, while the colon primarily resides on the left. The occurrence of acute appendicitis in mid-gut anomalies poses a serious diagnostic challenge due to unprecedented clinical and imaging features. Here we present a 20-year-old female who came to the hospital with left lower abdominal pain of 3 weeks duration, referred with a diagnosis of tubo-ovarian abscess. Further evaluation with an abdominopelvic CT scan revealed ileocecal junction in the left lower quadrant with a well-defined appendiceal abscess. The absence of a prior diagnosis of nonrotation, combined with the atypical presentation of pain, complicates the diagnosis of appendicitis. We emphasize the significance of considering left-sided appendicitis as a potential diagnosis for left-sided abdominal pain and recommend early cross-sectional imaging to prevent complications and improve surgical outcomes.

A case of isolated malrotation without midgut volvulus diagnosed prenatally and treated by laparoscopic surgery

BACKGROUND

Malrotation is a congenital condition that predisposes individuals to midgut volvulus, which can result in significant bowel resection. While most cases of malrotation are diagnosed by the age of 1 year, typically presenting with symptoms related to volvulus or bowel obstruction, some cases remain asymptomatic. In children with visceral malposition, gastroschisis, omphalocele, or diaphragmatic hernia, malrotation may be suspected before symptoms manifest. However, isolated malrotation without midgut volvulus diagnosed prenatally is rare. We herein present a case of isolated malrotation without midgut volvulus that was prenatally diagnosed and successfully treated with laparoscopic surgery.

CASE PRESENTATION

A 30-year-old woman (gravida 3, para 1) underwent routine obstetric ultrasound, which revealed increased blood flow in the lower uterine segment and abnormal placental attachment. To rule out placenta percreta, magnetic resonance imaging was performed at 34 weeks of gestation. Incidentally, abnormal fetal intestinal arrangement was noted, with the colon localized in the left hemi-abdomen and the small intestine distributed in the right hemi-abdomen, raising suspicion of malrotation. Postnatal contrast studies confirmed the diagnosis of malrotation without midgut volvulus. Given the risk of midgut volvulus, a laparoscopic Ladd's procedure was performed on day 6 of life. The postoperative course was uneventful, and the patient was still symptom-free 1 year postoperatively.

CONCLUSIONS

This case illustrates that malrotation can be prenatally diagnosed using fetal magnetic resonance imaging. Considering the risk of midgut volvulus, prophylactic Ladd's procedure should be performed in neonatal period. In cases where malrotation is not complicated by midgut volvulus, a laparoscopic Ladd procedure can be safely performed in neonates.

Mesenteric Base Width: Abdominal Wall Diameter Correlates With Intestinal Rotational Anomalies in Infants

INTRODUCTION

Symptomatic malrotation requires urgent Ladd procedure. Patients with incidental or indeterminate findings have historically been managed with observation or operatively. Fluoroscopic identification of the duodenojejunal junction (DJJ) and ileocecal junction (ICJ) can guide operative decision-making, but algorithms have not been validated. This study aimed to determine whether fluoroscopic mesenteric base width (MBW) standardized to abdominal wall diameter (AWD) correlates with intraoperative anatomy in infants.

METHODS

We retrospectively reviewed patients between 2013 and 2023 who were <1 year with fluoroscopy identifying DJJ and ICJ. Infants with normal rotation evaluated for digestive concerns were included. Congenital conditions with intestinal nonrotation were excluded. Two radiologists independently measured MBW as a diagonal line from DJJ to ICJ and maximal transverse AWD from inferior ribs. A ratio was calculated and compared between groups. Wilcoxon rank-sum and Kruskal-Wallis tests with p < 0.05 were considered significant. Area under the receiver operating characteristic curve (AUROC) was used to identify optimal ratio cutoff.

RESULTS

Fifty-eight patients, 22 normally rotated and 36 with intestinal rotational abnormality (IRA), met inclusion criteria. Preoperative radiographic concern for malrotation differed between groups (p < 0.0001). Median MBW:AWD was significantly lower in IRA than normal rotation based on imaging (0.31 vs 0.65, p < 0.0001). Optimal MBW:AWD of 0.55 had an AUROC of 0.9578.

CONCLUSIONS

Radiographic measurement of MBW:AWD accurately predicted IRA from normal rotation with an optimal ratio cutoff of 0.55. Further validation will determine whether this ratio should play a role in management of incidental IRA or indeterminate findings on UGI.

LEVEL OF EVIDENCE

III.

Performance of Prenatal Ultrasound Screening for the Relative Positioning of Mesenteric Vessels

OBJECTIVES

Abnormal relative positioning of the superior mesenteric artery (SMA) and vein (SMV) can lead to intestinal malrotation that predisposes to midgut volvulus. The aim of this study was to assess the prenatal ultrasound ability to visualize the relative position of SMA and SMV in normal pregnancies.

METHODS

Prospective cohort study performed in Montpellier University Hospital Centre, including 80 fetuses during routine 3rd trimester ultrasound scan. For each fetus included, the relative position of the vessels on an axial image was defined as SMV on the right, forward, or on the left of SMA. Doppler imaging was additionally used if necessary. Data were compared to the neonatal abdominal scans performed by pediatric radiologist.

RESULTS

The superior mesenteric vessels were identified in 79 fetuses. Prenatal findings showed a usual relative position of the vessels, that is, the vein on the right of the artery, in 96.2%. In 2 cases, the vein was strictly in front of the artery, and in 1 case, the vein was on the left side of the artery. Seventy-four neonates were examined and comparison with prenatal finding showed a perfect agreement (Kappa coefficient of 100%). An intestinal malrotation was postnatally diagnosed corresponding to the case where vein was on the left side of the artery.

CONCLUSION

This study showed that the relative position of the SMA and SMV could be assessed using ultrasound prenatal examination with a perfect agreement with postnatal findings. In case of abnormal vessels positioning more examinations should be promote including prenatal MRI and postnatal conventional radiologic examinations to confirm intestinal malrotation.

An atypical basement membrane forms a midline barrier during left-right asymmetric gut development in the chicken embryo

Correct intestinal morphogenesis depends on the early embryonic process of gut rotation, an evolutionarily conserved program in which a straight gut tube elongates and forms into its first loops. However, the gut tube requires guidance to loop in a reproducible manner. The dorsal mesentery (DM) connects the gut tube to the body and directs the lengthening gut into stereotypical loops via left-right (LR) asymmetric cellular and extracellular behavior. The LR asymmetry of the DM also governs blood and lymphatic vessel formation for the digestive tract, which is essential for prenatal organ development and postnatal vital functions including nutrient absorption. Although the genetic LR asymmetry of the DM has been extensively studied, a divider between the left and right DM has yet to be identified. Setting up LR asymmetry for the entire body requires a Lefty1+ midline barrier to separate the two sides of the embryo, without it, embryos have lethal or congenital LR patterning defects. Individual organs including the brain, heart, and gut also have LR asymmetry, and while the consequences of left and right signals mixing are severe or even lethal, organ-specific mechanisms for separating these signals are poorly understood. Here, we uncover a midline structure composed of a transient double basement membrane, which separates the left and right halves of the embryonic chick DM during the establishment of intestinal and vascular asymmetries. Unlike other basement membranes of the DM, the midline is resistant to disruption by intercalation of Netrin4 (Ntn4). We propose that this atypical midline forms the boundary between left and right sides and functions as a barrier necessary to establish and protect organ asymmetry.

Intestinal malrotation in the adult population: Diagnosis, management, and outcomes after laparoscopic Ladd procedure

BACKGROUND

The Ladd procedure is the treatment of choice for patients with intestinal malrotation; however, the long-term outcomes of the laparoscopic Ladd procedure are not well documented. This study aimed to review the presentation, management, and outcomes of adult patients who underwent a laparoscopic Ladd procedure.

METHODS

A retrospective review was conducted to identify adult patients with malrotation who underwent a laparoscopic Ladd procedure between January 1995 and June 2022 at the Mayo Clinic in Rochester, Minnesota. Patient details and follow-up data were obtained from the electronic medical records. Patients were invited to participate in a structured phone interview to assess symptoms and quality of life (QoL).

RESULTS

A total of 44 patients underwent the laparoscopic Ladd procedure. Of the 44 patients, 42 (95.5 %) were symptomatic, with 7 (16.7 %) presenting with acute symptoms. Moreover, 8 laparoscopic procedures (13.6 %) required conversion to an open procedure. The median estimated blood loss was 20 mL (IQR, 10-50), operative time was 2.3 h (IQR, 1.8-2.8), and hospital length of stay was 2 days (IQR, 2-3). Postoperative ileus was the most common complication (18.0 %). The median follow-up was 8.00 years (IQR, 2.25-13.00), with more than 90.0 % of patients having partial or complete symptom resolution. Of note, 28 patients (63.6 %) completed phone interviews. Moreover, 1 patient (2.0 %) reported a postoperative volvulus. When asked to compare their current symptoms with those preoperatively, 78.6 % of patients noted that they were significantly better. Furthermore, 85.7 % of patients reported that their QoL was significantly better after surgery. Finally, 96.4 % of patients would recommend the procedure to a friend or family member with the same condition.

CONCLUSION

The laparoscopic Ladd procedure is a safe and effective surgical procedure for adult patients with intestinal malrotation.

High risk and low incidence diseases: Pediatric digestive volvulus

INTRODUCTION

Pediatric digestive volvulus is a serious condition that carries with it a high rate of morbidity and mortality.

OBJECTIVE

This review highlights the pearls and pitfalls of pediatric digestive volvulus, including the presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Pediatric digestive volvulus is a deadly condition most commonly associated with malrotation. It occurs when the stomach or small intestine twists on itself, resulting in ischemia and potentially strangulation with necrosis and perforation. Presentation differs based on the gastrointestinal (GI) segment affected, degree of twisting, and acuity of the volvulus. Gastric volvulus most commonly presents with retching with or without nonbilious emesis and epigastric distension with pain, while midgut volvulus typically presents with bilious emesis in infants. Patients with GI necrosis and perforation may present with hemodynamic compromise and peritonitis. If suspected, emergent consultation with the pediatric surgery specialist is necessary, and if this is not available, transfer to a center with a pediatric surgeon is recommended. Imaging includes plain radiography, ultrasound, or upper GI series, while treatment includes resuscitation, administration of antibiotics, and emergent surgical decompression and detorsion of the involved segments.

CONCLUSION

An understanding of pediatric digestive volvulus and its many potential mimics can assist emergency clinicians in diagnosing and managing this deadly disease.

Clinical management of intestinal malrotation in different age groups

PURPOSE

Intestinal malrotation, characterized by abnormal intestinal positioning, can lead to severe complications like volvulus and internal hernias, especially in neonates and children. Our aim was to evaluate the diagnostic methods, treatment results and postoperative follow-up of pediatric patients treated for intestinal malrotation.

METHODS

This retrospective study reviewed medical records of pediatric patients who underwent surgery for intestinal malrotation between January 2013 and January 2022. Data on demographics, symptoms, diagnostic approaches, surgical interventions, and postoperative outcomes were analyzed.

RESULTS

The study included 45 patients, with a male predominance (68.8%). Ages ranged from 1 day to 15 years, averaging 1.54 years. Presenting symptoms were acute abdomen (n = 21) and chronic abdominal pain with vomiting (n = 24). Diagnoses were established via physical exams and imaging, including upper gastrointestinal contrast studies and abdominal ultrasonography. All patients received the Ladd procedure, with some requiring necrotic bowel resection due to volvulus.

CONCLUSION

The diagnosis and management of pediatric intestinal malrotation present significant challenges due to its variable symptoms and potential for life-threatening complications. Early and accurate diagnosis, followed by appropriate surgical management, is crucial. This study emphasizes the importance of diligent postoperative follow-up to identify and mitigate complications, particularly in younger and severely affected patients.

Impact of Focused Abdominal Ultrasound Utilization on Outcomes for Children With Midgut Volvulus

BACKGROUND

Ultrasound (US) is gaining acceptance for the evaluation of midgut volvulus in children. However, its impact on clinical outcomes is unknown. We aim to determine whether using US as a first-line modality changes imaging mobilization, time to surgery and re-feeding, length of stay, and frequency of bowel necrosis, short bowel syndrome, and death.

METHODS

An IRB-approved retrospective cohort study was performed at a tertiary pediatric institution. Eighty children with surgically confirmed midgut volvulus from 2014 to 2021 were compared before and after implementation of US as first-line imaging and based on the modality used to diagnose midgut volvulus.

RESULTS

Outcomes were not statistically different pre- versus post-implementation. Compared with patients who had UGI only, those who had US only or both had significantly quicker imaging mobilization (median: -33 min; 95% CI: -61.2, -4.8; p = 0.023 and median: -31 min; 95% CI: -58.5, -3.6; p = 0.028 respectively). Patients with US only were less likely to have bowel necrosis compared with those who had UGI only (9.1% versus 43.8%, p = 0.042). Patients who had US only or both were less likely to develop short bowel syndrome compared to UGI only (4.8% US only, 0% both, 40% UGI only; p = 0.027 for US only, p = 0.005 for both).

CONCLUSIONS

No statistically significant change in outcomes was found after implementation of US as first-line imaging for midgut volvulus. However, patients diagnosed with US only or US in combination with UGI had quicker imaging mobilization and decreased frequency of bowel necrosis and short bowel syndrome. Findings suggest that US has potential to improve patient outcomes.

LEVEL OF EVIDENCE

III.

No safe time window in malrotation and volvulus: A consecutive cohort study

BACKGROUND

Malrotation and volvulus classically present with bilious vomiting. It is more common earlier in life, but there are other causes of bile-stained vomiting. This leads some clinicians to 'watch and wait'. In the presence of a volvulus, this is potentially a fatal decision. It is not clear from the literature if there is a safe time window in which children can be observed in the hope of avoiding transfers or radiological investigations.

AIM

To determine whether time to identification and management of midgut volvulus correlated with morbidity and mortality; and whether there were patterns to transition of care.

METHODS

Multicentre, retrospective review of all children with malrotation ± volvulus at two tertiary children's hospitals in Brisbane from 2000 to 2012. Data collected included age at presentation, timing between symptom onset and presentation, radiological findings, and definitive surgical management. Outcomes included patient length of stay (LOS), total parenteral nutrition (TPN) duration, re-operations and death.

RESULTS

There were 96 cases of malrotation identified, with 23 excluded (elective operation, insufficient data). Neonates made up 66% of included cases. Only 14% of cases were over 12 months old. Bilious vomiting or bile-stained aspirates were the presenting symptoms in 71% (52). Overall mortality was 5.56%. Time from symptom onset to presentation or management was not significantly associated with morbidity or mortality. More than half (53%, 39/73) of patients received total parenteral nutrition; 20/39 for more than 10 days. Neonates and infants had a significantly higher rate of TPN compared with older children (P < 0.001). Those requiring TPN post-operatively had a significantly higher mortality compared with those who did not (P = 0.02). Time from symptom onset to presentation or definitive management was not significantly associated with LOS, TPN duration, or need for re-operation.

CONCLUSION

Malrotation remains a time-critical diagnosis to secure and treat. Even a short duration of symptoms can be associated with high morbidity or mortality. There is no place for 'watch and wait' for such patients, and malrotation/volvulus should be emergently actively excluded with contrast studies.

Notable Clinical Differences Between Neonatal and Post-Neonatal Intestinal Malrotation: A Multicenter Review in Southern Japan

BACKGROUND

Most cases of intestinal malrotation appear in neonates with bilious vomiting due to midgut volvulus, whereas in cases that develop beyond infancy, the initial symptoms vary. This study investigated the clinical features of these two populations and identified issues that should be considered in daily practice.

METHODS

A retrospective chart review was conducted from January 1, 2010, to December 31, 2022. Data on patients with intestinal malrotation were collected in an anonymized fashion from five pediatric surgical hub facilities in the Southern Kyushu and Okinawa areas of Japan.

RESULTS

Of the 80 subjects, 57 (71.3%) were neonates (Group N) and 23 (28.7%) were infants and schoolchildren (Group I). The frequencies of initial symptoms, such as abdominal distention (Group N: 19.3% vs. Group I: 13.0%), bilious vomiting (59.6% vs. 43.5%), and hematochezia (8.8% vs. 21.7%), were not skewed by the age of onset (p = 0.535, 0.087, and 0.141, respectively). Midgut volvulus was significantly more frequent in Group N (71.9% [41/57] vs. 34.8% [8/23]; p = 0.005), while the degree of torsion was greater in group I (median 360° [interquartile range: 180-360°] vs. 450° [360-540°]; p = 0.029). Although the bowel resection rate was equivalent (7.0% [4/57] vs. 4.3% [1/23]; p = 1.000), half of the patients in Group N presented with 180° torsion. The neonatal intestine has been highlighted as being more susceptible to ischemia than that in older children.

CONCLUSIONS

The incidence of midgut volvulus is higher in neonates than in older children. Even relatively mild torsion can cause ischemic bowel changes during the neonatal period.

LEVEL OF EVIDENCE

LEVEL III.

Adult-onset congenital intestinal malrotation: A case report and literature review

BACKGROUND

Intestinal malrotation is an infrequent congenital anomaly primarily observed in neonates, and adult-onset cases are exceedingly rare. Studies on adult congenital intestinal malrotation are limited.

METHODS

A case with congenital intestinal malrotation is reported in our study. The clinical data were collected and the treatment process and effect were evaluated.

RESULTS

A 45-year-old female who had been experiencing vomiting for over 40 years was admitted to our hospital. According to the result of CT scan, intestinal volvulus accompanied by bowel obstruction was suspected. Then laparoscopic examination was applied to the patient and was ultimately diagnosed with adult congenital intestinal malrotation. We performed Ladd's procedure combined with gastrojejunostomy and Braun anastomosis. The patient recovered well and was successfully discharged from the hospital on the 13th day after surgery. After a 6-month follow-up, the symptom of vomiting was significantly alleviated and body weight was gained for 10 kg. She was very satisfied with the treatment.

CONCLUSION

Adult congenital intestinal malrotation is a rare disease that is often misdiagnosed owing to nonspecific clinical manifestations. Therefore, awareness about this condition should be enhanced. Surgery remains the cornerstone of treatment for this disease. Combining gastrojejunostomy and Braun anastomosis with the traditional Ladd procedure can optimize surgical outcomes.

Developmental regulation of cellular metabolism is required for intestinal elongation and rotation

Malrotation of the intestine is a prevalent birth anomaly, the etiology of which remains poorly understood. Here, we show that late-stage exposure of Xenopus embryos to atrazine, a widely used herbicide that targets electron transport chain (ETC) reactions, elicits intestinal malrotation at high frequency. Interestingly, atrazine specifically inhibits the cellular morphogenetic events required for gut tube elongation, including cell rearrangement, differentiation and proliferation; insufficient gut lengthening consequently reorients the direction of intestine rotation. Transcriptome analyses of atrazine-exposed intestines reveal misexpression of genes associated with glycolysis and oxidative stress, and metabolomics shows that atrazine depletes key glycolytic and tricarboxylic acid cycle metabolites. Moreover, cellular bioenergetics assays indicate that atrazine blocks a crucial developmental transition from glycolytic ATP production toward oxidative phosphorylation. Atrazine-induced defects are phenocopied by rotenone, a known ETC Complex I inhibitor, accompanied by elevated reactive oxygen species, and rescued by antioxidant supplementation, suggesting that malrotation may be at least partly attributable to redox imbalance. These studies reveal roles for metabolism in gut morphogenesis and implicate defective gut tube elongation and/or metabolic perturbations in the etiology of intestinal malrotation.

Ultrasound as the first line investigation for midgut malrotation: a UK tertiary centre experience

AIM

To present the first 22-months experience of transitioning to an ultrasound-first pathway for suspected midgut malrotation.

MATERIALS AND METHODS

An "ultrasound-first" imaging pathway was initiated in October 2021. Twenty-two-months later, a search was undertaken of all <1-year-old patients with "bilious", "malrotation," or "volvulus" as the imaging indication. Reports and images from upper gastrointestinal fluoroscopy (UGI) and ultrasound were reviewed, and diagnoses and outcomes were documented.

RESULTS

The search yielded 101 eligible cases between October 2021 and July 2023. Of the patients, 63/101 (62%) had both ultrasound and UGI: 47/63 (75%) ultrasound first, 16/63 (25%) UGI first. Thirty-one per cent (31/101) had ultrasound only and 7/70 (10%) UGI only. The pathway diagnosed 7/8 (88%) infants with midgut malrotation with or without volvulus and one infant who had an inconclusive ultrasound examination with a suspected an internal hernia and who was found to have malrotation volvulus at surgery. Twenty-one infants who had confidently normal ultrasound examinations and who also had UGI all had a normal duodenojejunal flexure position. Ultrasound detected alternative pathology in eight children. Duodenal visualisation improved with time: 6/15 (40%) in the first 6 months to 23/34 (68%) after the first year.

CONCLUSION

The transition to ultrasound as the first diagnostic test for midgut malrotation can be done safely and effectively in a UK centre, which previously relied solely on UGI.

A rare case of Ladd's band causing duodenal occlusion in an adult with intestinal malrotation

A congenital defect of the fetal intestinal rotation, known as malrotation of the gut, is most often identified as an acute intestinal occlusion in early infancy. Adults with this disease tend to be asymptomatic and extremely rare. We present a case of a 47-year-old woman with duodenal obstruction due to Ladd's band admitted with acute abdominal pain and vomiting.

Recurrent caecal volvulus in an adult: Should we practice coecopexy systematically at neonatal age for incomplete common mesentery? A case report

INTRODUCTION AND IMPORTANCE

Malrotation is usually revealed early in infancy and or later in childhood, even more unusually in adulthood. This disorder is treated through Ladd's procedure. Literature is limited on the long-term outcomes of this approach, especially into adulthood.

CASE PRESENTATION

We present a case of a 33 years male with a history of a laparotomy as a new born for a bowel obstruction secondary to malrotation, presenting with an obstruction and colonic volvulus. Laparotomy reveals a volvulus of the coecum secondary to a failure of the coecum to attach during surgery performed at neonatal age.

CLINICAL DISCUSSION

For a patient operated on during the neonatal period for intestinal malrotation, the examination for sub occlusive episodes should suggest a recurrence of malrotation such as coecal volvulus, and the possibility of technical malfunction during the previous procedure. This reflection leads us to consider the necessity of performing coecopexy systematically during the first surgery.

CONCLUSION

Ladd's technique is the surgical treatment of the incomplete common mesentery. The fixation of the coecum could be done in a systematic way to prevent a possible coecal volvulus which can be responsible for digestive necrosis and often even a fulminant evolution.

Fetal malrotation with midgut volvulus: Prenatal diagnosis and planning

Introduction

Malrotation of the intestinal tract is a congenital malformation commonly found either incidentally or after affected individuals develop signs and symptoms of intestinal obstruction. Malrotation is prone to midgut volvulus that can cause intestinal obstruction and lead to ischemia and necrosis requiring emergent surgical intervention. Rare instances of in utero midgut volvulus have been reported in the literature and carry a high mortality given the difficulty in establishing a diagnosis prior to development of signs of intestinal ischemia and necrosis. Advancements in imaging have made it possible to diagnose in utero malrotation earlier, raising the question of optimal timing of delivery, especially in cases of prenatally diagnosed midgut volvulus. In these cases, the risks of premature birth must be weighed against the risks of fetal intestinal ischemia and potential fetal demise.

Case presentation

This case report details an interesting presentation of intestinal malrotation with suspected midgut volvulus found on prenatal imaging at 33 weeks and 4 days' gestation. This prompted delivery of the infant at 34 weeks and 2 days' gestation with urgent operative management, within 3 hours of life, after diagnosis was confirmed postnatally. Intraoperatively, the infant was confirmed to have midgut volvulus without bowel ischemia, the intestines were reduced, and a Ladd procedure was performed without incident. The infant recovered postoperatively without complication, tolerated advancement to full volume feeds and was discharged on day of life 18.

Conclusion

Successful management of fetal malrotation with midgut volvulus may be accomplished by early access to a multi-disciplinary team of professionals, prompt postnatal confirmation of diagnosis, and urgent correction to minimize the risk of complications.

Malrotation and Fibroblast Growth Factor Receptor-2-Associated Craniosynostosis: An Underrecognized Association and Management Pathway

INTRODUCTION

Feeding difficulties are common and multifactorial in children with Fibroblast Growth Factor Receptor-2 (FGFR-2) mutations. Intestinal rotation anomalies have been demonstrated to occur more frequently in animals with FGFR-2 mutations. This study aims to describe intestinal rotation anomalies, surgical management, and feeding assistance in children with FGFR-2 mutations who have undergone upper gastrointestinal (UGI) contrast studies.

METHODS

Retrospective data were collected of children born between 1988 and 2020 in a UK quaternary craniofacial unit with FGFR-2-associated craniosynostosis. A consultant survey of approach to malrotation was undertaken.

RESULTS

Thirty-four children were included, 17 (50%) female. Six (18%) had UGI symptoms, which included bilious vomiting (n=2), nonbilious vomiting (n=5), retching (n=1), feed intolerance (n=3), and failure to thrive (n=3). Nine had a gastrostomy in situ. Intestinal rotation anomalies occurred in 4 (12%) children, 3 of whom underwent a Ladd procedure and two third required gastrojejunal feeding postoperatively. Consultants agreed that all children with FGFR-2 mutation and UGI symptoms should undergo UGI contrast study, as should children requiring a gastrostomy.

DISCUSSION

Intestinal rotation anomalies in children with FGFR-2 mutations occur more frequently than the general population. Prompt consideration of UGI contrast in symptomatic children with FGFR-2 mutation is recommended to enable early surgical management of children with malrotation.

A case of intestinal malrotation apparent after laparoscopically total proctocolectomy followed by ileal-pouch-anal anastomosis for ulcerative colitis

Intestinal malrotation (IM) is an abnormality due to a failure of the normal midgut rotation and fixation. We report a case of 46-year-old man with ulcerative colitis whose IM was apparent after laparoscopically total proctocolectomy (TPC) followed by ileal-pouch-anal anastomosis (IPAA) and ileostomy. There was no abnormal anatomy except for mobile cecum/ascending colon during the initial operation. Intestinal obstruction occurred after ileostomy closure. The computed tomography scan showed the duodeno-jejunal transition was located in right abdomen, the superior mesenteric vein was located left of the superior mesenteric artery (SMA) and the obstruction point was the distal ileum near the pouch. We performed an ileo-ileo bypass across the ventral side of the SMA to relieve the intestinal obstruction. The patient would have incomplete IM preoperatively, which became apparent by TPC. In case of TPC for mobile colon, anatomy of small intestine should be checked before IPAA.

Income disparities in nationwide outcomes of malrotation with midgut volvulus

BACKGROUND

Malrotation with midgut volvulus is a surgical emergency commonly encountered in pediatric surgical practice. Outcomes are excellent with timely diagnosis and treatment, but the development of bowel ischemia is associated with many negative consequences.

METHODS

The Nationwide Readmissions Database was used to identify patients 0-18 years (excluding newborns) with malrotation and midgut volvulus from 2010 to 2014. Demographics, procedures, and outcomes were compared by income group (highest quartile vs. lowest quartile) using standard statistical tests. Results were weighted for national estimates.

RESULTS

Emergency surgery for midgut volvulus was performed in 572 patients. The majority (86%) underwent Ladd's procedure, while 14% required bowel resection and/or ostomy. Patients in the lowest income quartile were more likely to require bowel resection (18% vs. 8%, p = 0.03) or ostomy (9% vs. 2%, p = 0.015) compared to those in the highest income quartile. Low-income patients were more likely to experience prolonged hospital stay (8 [5-13] days vs. 6 [4-8] days, p<0.001) and experience complications including infections (19% vs. 5%, p = 0.002), endotracheal intubation (18% vs. 4%, p<0.001), and blood transfusions (13% vs. 3%, p = 0.003).

CONCLUSION

Income disparity represents a major factor in surgical outcomes in children with midgut volvulus. A broad spectrum of clinical outcomes following surgery for midgut volvulus exists. Patients from lower-income communities are at significantly higher risk for numerous complications, negative outcomes, and higher resource utilization. These findings support additional investigations of practices to mitigate risk for low-income patients.

LEVEL OF EVIDENCE

Level III: Retrospective comparative study.

Importance of Second-Look Surgery in a Newborn Presenting With Early Malrotation

Intestinal malrotation refers to the abnormal positioning of the intestines due to a deviation from normal developmental stages. Volvulus is seen in 60%-70% of neonates diagnosed with intestinal malrotation. We are reporting a case of s six-day-old male who presented with multiple episodes of bilious vomiting and constipation and had malrotation of intestines with midgut volvulus. After a contrast upper GI study, the patient was taken for exploratory laparotomy, and extensive patches of an early stage of bowel ischemia were observed; resection was avoided at this stage. In the second-look surgery, all the gangrenous bowel loops were resected, and anastomosis was done.

Approach to the Adult Colorectal Patient with a History of Pediatric Abdominal Surgery

Children with colorectal diseases often undergo operative management in their youth. As these patients become adult, it is important for surgeons to understand their postoperative anatomy as well as the pathophysiology of their diseases. Here, we present a description of common colorectal diseases of childhood that may have significant impact on patients' presentations as adult. We also discuss the diagnosis and management of conditions that are usually seen early in life but may present during adulthood as well.

A digital audit of emergency upper gastrointestinal fluoroscopy workflow in children with bilious vomiting

Background

Bilious vomiting in children requires an urgent evaluation with upper gastrointestinal (UGI) fluoroscopy as it may herald life-threatening midgut malrotation with volvulus (MMWV). There are no published data available on the duration of time-critical UGI workflow steps.

Objectives

A digital audit of workflow in emergency UGI contrast studies performed on children with bile-stained vomiting at a large South African teaching hospital.

Method

A retrospective study was conducted from 01 May 2012 – 31 May 2019. A customised search of the institutional radiology information system (RIS) defined all children with bilious vomiting who underwent emergency UGI fluoroscopy. Extracted RIS timestamps were used to calculate the median duration of the ‘approval’, ‘waiting’, ‘study’ and ‘reporting’ times. One-way analysis of variance and Chi-squared tests assessed the association between key parameters and the duration of workflow steps, with 5% significance (p < 0.05).

Results

Thirty-seven patients (n = 37) with median age 0.8 months were included, of whom 20 (54%) had an abnormal C-loop. The median ‘total time’ from physician request to report distribution was 107 min (interquartile range [IQR]: 67−173). The median ‘approval’ (6 min; IQR: 1–15) and ‘reporting’ (38 min; IQR: 17–91) times were the shortest and longest workflow steps, respectively. Abnormal C-loops (p = 0.04) and consultant referrals (p = 0.03) were associated with shorter ‘approval’ times. The neonatal ‘waiting’ time was significantly longer than that for older patients (p = 0.02).

Conclusion

The modern RIS is an excellent tool for time-critical workflow analyses, which can inform interventions for improved service delivery.

Ultrasound for Midgut Malrotation and Midgut Volvulus: AJR Expert Panel Narrative Review

Midgut volvulus in association with malrotation is a pediatric surgical emergency. Prompt and accurate diagnosis is necessary to avoid bowel ischemia and necrosis, thereby reducing morbidity and mortality. Historically, the upper gastrointestinal (UGI) series has been the preferred imaging modality for the evaluation of both midgut malrotation and volvulus, although use of ultrasound (US) is increasing. In this narrative review, we describe the findings of midgut malrotation and volvulus on US, including practical tips for acquisition and interpretation; discuss the advantages and challenges of both imaging modalities; and propose a path and safeguards for possible transition to the use of US as the first-line modality for diagnosis, based on our experience in imaging children with midgut malrotation and volvulus.

Case report of congenital intestinal malrotation in an adult discovered three months status-post appendectomy

Introduction and importance

Intestinal malrotation is a congenital anomaly primarily diagnosed in children, with limited cases reported in adults. Prompt recognition is necessary to prevent life-threatening complications including bowel ischemia and death. We present a rare case of adult intestinal malrotation highlighting difficulty in diagnosis and surgical management.

Case presentation

A 37-year-old Caucasian woman presented with a 3-day history of worsening diffuse abdominal pain, three months status-post laparoscopic appendectomy. CT scan with contrast of the abdomen and pelvis demonstrated small bowel mesenteric swirling and descending duodenal transition point. Differential diagnosis included intestinal malrotation versus small bowel obstruction. Pre-operatively, the patient expressed frustration with years of abdominal pain and lack of improvement. Treatment with open surgical small bowel detorsion and ligation of the Ladd's bands was performed, after initial laparoscopic intervention was complicated by enterotomy. The patient recovered well post-operatively with final diagnosis of intestinal malrotation with midgut volvulus. Discharge home was delayed due to polysubstance withdrawal. Post-operatively, the patient reported immediate relief of symptoms which persisted at 2-week and 2-month follow-ups.

Clinical discussion

Few reports of congenital malrotation diagnosed in adulthood are reported. This highlights the importance of evaluating all patients for malrotation when the appendix is found outside of the normal positioning in the RLQ, as surgical correction of malrotation is of utmost importance in such patients.

Conclusion

Clinicians should consider intestinal malrotation in adults with recurrent vague abdominal symptoms. To our knowledge, this is the first report of congenital malrotation discovered in an adult after prior appendectomy.

•

Congenital intestinal malrotation diagnosed in adults is scarcely reported.

•

No guidelines exist for the management of malrotation in adult patients.

•

To our knowledge, this is the first report of intestinal malrotation discovered after previous appendectomy.

A problem at any age: a case report of congenital malrotation with bowel ischemia in an 84-year-old

Background

Malrotation with bowel ischemia is classically thought of as a disease of infants. However, the true prevalence of malrotation in both the pediatric and adult population is unknown due to the unclear number of asymptomatic patients.

Case presentation

A previously healthy 84-year-old man with no prior abdominal surgeries presented with an acute abdomen and was found on CT to have small bowel located in the right hemiabdomen and an abnormal SMA-SMV relationship suggestive of intestinal malrotation, as well as pneumatosis intestinalis. He underwent an exploratory laparotomy, where he was found to have a paraduodenal space which did not contain any bowel but was the likely source of an internal hernia. His duodenojejunal flexure was located to the right of the spinal column, the cecum in the left lower quadrant, a thick congenital band at the proximal jejunum, and multiple Ladd’s bands at the level of the duodenum. The bowel appeared viable and a Ladd’s procedure was performed. The patient had an uneventful post-operative course.

Conclusions

There is a lack of guidelines regarding screening for and management of asymptomatic malrotation in older children and adults. However, the traditional thinking is that asymptomatic malrotation diagnosed after two years of age poses minimal risk. This case illustrates the potential risk of an internal hernia in the setting of malrotation at any time during one’s lifetime.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01482-6.

18-year-old with Abdominal Pain Due to Congenital Bowel Malrotation: A Case Report

Introduction: Congenital bowel malrotation resulting in midgut volvulus is traditionally regarded as a diagnosis of infancy. Rarely, congenital bowel malrotation is diagnosed in adolescents or adults and requires a high index of suspicion. Presentations can be acute or chronic, and physical examination findings are nonspecific. Diagnosis is primarily achieved through abdominal computed tomography (CT) or during exploratory laparotomy. The pathophysiology in late-onset malrotation is similar to neonatal malrotation, with a division of Ladd’s bands – peritoneal fibrous bands that connect the cecum to the right lower quadrant retroperitoneum – as the definitive treatment. We present a case of congenital bowel malrotation in an adolescent with persistent and worsening migratory abdominal pain. Case Report: An 18-year-old female presented to the emergency department with two days of poorly localized abdominal pain and nausea. Initial evaluation was unremarkable and she was discharged home with a diagnosis of constipation. She returned two days later with worsening abdominal pain and new onset emesis. Given her persistent and worsening symptoms an abdominal CT was performed, which revealed malrotation of the bowel. Taken together, her CT findings and abdominal symptoms were concerning for symptomatic congenital bowel malrotation and she underwent a Ladd procedure. She remained asymptomatic both at discharge and at two-week postoperative follow-up. Conclusion: Symptomatic congenital bowel malrotation is more common in older children and adults than has traditionally been thought. Physicians must consider this diagnosis in their differential when working up a patient for acute or chronic intermittent abdominal pain to prevent potentially severe sequelae.

Sonographic Detection of Congenital Intestinal Malrotation: A Case Report

Intestinal malrotation is a rare fetal anomaly resulting from the failure of midgut rotation and fixation. Sonography is typically the first modality of choice for assessing pediatric pathology due to its high sensitivity, portability, real-time imaging capability, and non-ionizing technique; however, its role in diagnosing small bowel rotational anomalies remains limited and controversial. Fluoroscopic upper gastrointestinal imaging (UGI) is the primary diagnostic examination at most institutions. However, even on UGI, imaging findings may be equivocal. In such cases, sonography may provide additional information at facilities where it is not used as a primary diagnostic tool. This case report represents the first reported case showing how patient position is important as the typical vascular sonographic features of rotation were normal in one position but abnormal in another. In addition, this case shows how congenital intestinal malrotation was decisively diagnosed using sonographic imaging.

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

OBJECTIVES

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.

METHODS

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.

RESULTS

27 cases of malrotation were confirmed (mean age 62 ± 9 years; 15 M/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).

CONCLUSIONS

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.

The multisystem nature of isomerism: left isomerism complicated by Abernethy malformation and portopulmonary hypertension

Isomerism, also referred to as "heterotaxy" is a complex set of anatomic and functional perturbations. One of the most obvious manifestations of isomerism is the disturbance of organ arrangement, such that the thoracic organs are no longer asymmetric on the left and right. We report the case of a 14-year-old female in whom exercise-induced dyspnea led to a late diagnosis of left isomerism complicated by Abernethy malformation and portopulmonary hypertension. A comprehensive evaluation revealed two anatomic left lungs and hyparterial bronchi, bilateral left atria, an interrupted inferior caval vein with azygos continuation, multiple spleens, sinus node dysfunction, hepatic hypertrophy with focal nodular hyperplasia, and absence of the portal vein. Pulmonary vasodilator therapy was initiated resulting in clinical improvement. This case exhibits unique features including a late diagnosis of isomerism with Abernethy malformation and portopulmonary hypertension. The patient's presentation, medical workup, and future treatment emphasise the importance of multidisciplinary care in children with complex multisystem disease. We review the multiple cardiac and extracardiac manifestations of isomerism.

The adequacy of fluoroscopic upper gastrointestinal studies for suspected intestinal volvulus in a tertiary care centre vs. secondary centres: A regional multicentre study

INTRODUCTION

Early diagnosis and treatment of intestinal volvulus are important to reduce morbidity. A fluoroscopic upper GI study is the gold standard for diagnosis and may be performed in a secondary or tertiary care centre prior to surgery. It is important the reporting radiologist is confident in the findings. We aim to assess whether there is any difference in confidence and study quality between paediatric and general radiologists who work in secondary or tertiary care centres.

METHODS

Retrospective review of initial radiology reports and blinded review of the study images by paediatric radiologists.

RESULTS

A total of 277 children underwent a fluoroscopic study for intestinal volvulus over a four-year period. The majority were performed at a tertiary care centre, by paediatric radiologists. The confidence of initial reporting was higher in paediatric than general radiologists despite whether they worked in a secondary or tertiary care centre (P-value < 0.001). On retrospective review, studies performed by paediatric radiologists were rated as having a higher confidence in identifying the location of the duodenojejunal flexure. General radiologists tended to have a slightly higher rate of repeat studies but still low at 2.2%. Despite this, there was no significant difference in the diagnosis rates and secondary centre general radiologists excluded malrotation in 62% of studies likely reducing transfer rates.

CONCLUSION

Confidence in initial reporting and on review of the duodenojejunal flexure location in suspected intestinal volvulus is higher in paediatric radiologists compared with general radiologists, although diagnosis rates are no different.

A case of midgut volvulus related to adult intestinal malrotation found with weight loss after streptococcus infection: A case report and literature review

INTRODUCTION AND IMPORTANCE

The incidence of intestinal malrotation is 1 in 6000 births, and 90% of cases occur within the first year of life. Adult cases are rare, with a reported incidence of 0.2%-0.5% of all cases. The significance of reporting this case is to recognize that some adult-onset cases require surgery even in the absence of intestinal necrosis.

CASE PRESENTATION

A 36-year-old man was infected with streptococcus and treated with antibiotics. He developed appetite loss and his weight decreased 12 kg in 4 months. His abdomen was flat and soft with no tenderness. A computed tomography scan showed that the horizontal duodenal leg was not anchored to the retroperitoneum. Rotation of the mesentery, which was wrapped around the superior mesenteric artery in a clockwise direction, was observed, suggesting midgut volvulus. We performed emergency surgery and Ladd's procedure.

CLINICAL DISCUSSION

A previous study reported that the most common symptom in the chronic course of intestinal malrotation was abdominal pain in 41.2% of cases, and weight loss was observed in only 2.6% of patients. The high degree of intestinal adhesion suggests that repeated torsion and release and the development of collateral vessels may have contributed to the asymptomatic course.

CONCLUSION

Adult-onset intestinal malrotation should be considered as a differential diagnosis in the presence of weight loss and gastrointestinal symptoms. The timing of surgery is still controversial. In chronic cases, severe adhesion might be expected and laparoscopic surgery should be considered carefully.

Mesenteric Vessel Abnormalities Detected With Sonography: A Possible Gateway to the Early Diagnosis of Various Gastrointestinal Anomalies

Background:

In pediatric sonography, mesenteric vessel abnormalities can be used as a sign of malrotation or volvulus. This study was aimed at evaluating the diseases associated with mesenteric vessel abnormalities in children, except for rotational anomalies.

Methods:

From 2017 to 2020, pediatric patients with abdominal complaints were referred for a full abdominal sonogram and were evaluated for mesenteric vascular abnormalities. During this period, 62 children (aged <12 years), with mesenteric vessel abnormalities, were discovered with sonography. They were also examined for associated anomalies and were followed until a final diagnosis was determined.

Results:

Mesenteric vessel displacement was reported in 37 patients (60%); in 24 cases, the vein was located to the left of superior mesenteric artery (SMA), and in others (13 cases), in the anterior position. Abnormal pathways in mesenteric vessels were reported in 33 patients (53%); 18 cases showing a right side turn and 15 cases showing a left side turn. The whirlpool sign was seen in 16 patients (27%). These three patterns of vessel abnormality were associated with disorders such as diaphragmatic hernia, bowel obstruction, and space occupying lesions (masses). The location of the mesenteric abnormality was in the proximal part of mesenteric vessels in 45 cases (72.5%) and in its distal part in 17 cases (27.5%). Malrotation (eight cases), obstruction, and volvulus were the most common causes of a distal abnormality.

Conclusions:

Mesenteric vessel abnormalities, noted with sonography, may not be exclusive to the diagnosis of malrotation and midgut volvulus. In this cohort, bowel obstruction, diaphragmatic hernia, and space occupying lesions were the other most common anomalies associated with mesenteric vessel abnormalities. In reviewing one-third of mesenteric vessels, abnormalities were only seen in the distal part of vessels; therefore, a thorough examination is warranted.

Adult Intestinal Malrotation in a Non-Paediatric Hospital in Trinidad: A Case Report and Literature Review

Intestinal malrotation (IM) is a congenital aberrancy of midgut rotation during development, which manifests among neonates more than adults. Older reports have estimated an incidence of one in 6,000 live births, which is now as high as one in 500. This congenital anomaly is generally indolent in the adult population. Recent literature research has failed to reveal any publications regarding the incidence within a Caribbean population. This paper aims to discuss the isolated case of a patient with this rare condition, who presented to a non-paediatric centre in Trinidad. This case highlights the implications of the initial radiological interpretation in conjunction with perioperative and intraoperative decision making.

An 18-year-old male presented with a one-day history of abdominal pain, radiating to the epigastrium with nausea and excessive vomiting. Vital signs and blood investigations were normal. Initial CT scan results were interpreted as an internal hernia, which was surgically managed as such. Repeat imaging and a second laparotomy were required to correctly diagnose and perform the appropriate Ladd procedure.

IM occurs due to the arrest of rotation of the midgut during fetal maturation. The incomplete rotation variant was seen in this case and is predominantly responsible for the symptomatology and morbidity associated with adult intestinal malrotation (AIM). Stringer has classified these anomalies based on the stage of embryonic development that is disrupted. CT helps with diagnostics in 97.5% of cases. This case highlights the implication of incorrect assessment on imaging and how it may misguide the interpretation of the findings at laparotomy leading to inappropriate surgical procedures. As many as 20% of cases undergo surgery without adult intussusception diagnosed.

The incidence of IM seems to have increased but is scarcely encountered in the adult setting. When encountering this condition at a low-volume centre in the Caribbean, the adult specialist may be blindsided, and unknowingly underprepared without a high index of suspicion. Diagnosis at childhood should be discussed with the family and again with the patient on approaching adulthood. Patient education may help with the surgical assessment.

The twists and turns of left-right asymmetric gut morphogenesis

Many organs develop left-right asymmetric shapes and positions that are crucial for normal function. Indeed, anomalous laterality is associated with multiple severe birth defects. Although the events that initially orient the left-right body axis are beginning to be understood, the mechanisms that shape the asymmetries of individual organs remain less clear. Here, we summarize new evidence challenging century-old ideas about the development of stomach and intestine laterality. We compare classical and contemporary models of asymmetric gut morphogenesis and highlight key unanswered questions for future investigation.

Assessment of plasma microRNAs in congenital intestinal malrotation

Intestinal malrotation in newborns often requires urgent surgical treatment, especially in the presence of volvulus. Therefore, early-stage diagnosis is critical. In the present study, differentially expressed plasma microRNAs (miRNAs) were screened for in patients with intestinal malrotation using high-throughput Illumina sequencing, and validated using reverse transcription-quantitative PCR. Receiver operating characteristic curve (ROC) analysis was conducted to evaluate their specificity, sensitivity and assess their diagnostic value for intestinal malrotation. Bioinformatics analysis was performed to investigate the functions associated with the dysregulated miRNAs. A profile consisting of 28 differentially expressed plasma miRNAs was obtained, of which nine were verified to exhibit significantly altered expression. According to a ROC analysis, four of these could represent novel early-stage, non-invasive biomarkers for intestinal malrotation. Bioinformatics analysis demonstrated that the differentially expressed miRNAs were predominantly involved in ‘metal ion transmembrane transporter activity’ and ‘calcium-dependent protein binding’, which may be related to the ‘endocytosis’ pathway. In conclusion, significantly differentially expressed plasma miRNAs were identified in congenital intestinal malrotation and their potential roles were described. These differentially expressed miRNAs may serve as biomarkers of intestinal malrotation and improve early diagnosis for this condition.

A Five Years Old Child with Failure To Thrive and Vomiting Presenting as a Diagnostic Dilemma: A Case Report

Vomiting with failure to thrive in older children is a diagnostic challenge due to the diversity in the diagnosis. We report a case of a five-years-old girl with failure to thrive, history of recurrent vomiting and intermittent colicky pain abdomen since 45 days of life. Intestinal malrotation with Ladd's band was diagnosed based on clinical acumen, high-resolution computed tomography, barium follow through and intraoperative findings. Exploratory laparotomy with Ladd's procedure was performed under general anesthesia which showed malrotation at the duodenojejunal junction with a short route of mesentery with floating caecum with Ladd's band. Failure to thrive with malrotation of the gut in the older age group is rare in itself. As there are very few cases reported in this age group, so we undertook to report this case to increase the awareness of knowledge concerning the diagnosis and timely management to prevent the comorbidity of this condition.

Midgut volvulus caused by intestinal malrotation; A rare cause of acute abdomen in adults. Case report

•

Midgut volvulus caused by malrotation.

•

Midgut volvulus as a rare cause of acute abdomen in adulthood.

•

Intestinal malrotation presentation in the adulthood.

Introduction

Acute abdomen due to midgut volvulus with intestinal malrotation is rare event with only only few cases in the literature Butterworth et al. (2018). Intestinal malrotation presented in the adulthood is reported in 0.2−0.5 %, of cases; with only 15 % f them presenting as midgut volvulus Butterworth et al. (2018).

Intestinal malrotation is casued by an alteration in embryonic development between 10–12 weeks of gestation. The main alteration is anomalous position of the bowel with the small intestine residing on the right side of the abdomen, while the colon and cecum remain on the left side due to malposition of the Treitz ligament. Additionally, the ascending colon remains attached to the abdominal wall by fibrous peritoneal bands known as Ladd bands, this being a cause of midgut volvulus and intestinal obstruction.

Presentation of Case

We present a 25-year-old male with failure to thrive who arrives at the ED with clinical signs and symptoms of intestinal occlusion and acute abdomen, initial resuscitation is made in ED and is transferred to OR, an exploratory laparoscopy evidencing intestinal malrotation with cecal volvulus and a Ladd procedure is made openly without PO complications.

Discussion

The gold standard for diagnosis of intestinal malrotation is the upper gastrointestinal series. However, in patients with acute abdomen associated with this pathology where is suspected intestinal ischemia and hemodynamic instability, it is essential that an emergency laparotomy be performed.

Conclusions

The diagnosis of intestinal malrotation is difficult, since many patients are asymptomatic in adulthood or present with variable GI symptoms. Therefore, it is imperative to have a high index of suspicion in patients with compatible clinical characteristics in order to perform the best therapy in time and manner.

Large intestine embryogenesis: Molecular pathways and related disorders (Review)

The large intestine, part of the gastrointestinal tract (GI), is composed of all three germ layers, namely the endoderm, the mesoderm and the ectoderm, forming the epithelium, the smooth muscle layers and the enteric nervous system, respectively. Since gastrulation, these layers develop simultaneously during embryogenesis, signaling to each other continuously until adult age. Two invaginations, the anterior intestinal portal (AIP) and the caudal/posterior intestinal portal (CIP), elongate and fuse, creating the primitive gut tube, which is then patterned along the antero‑posterior (AP) axis and the radial (RAD) axis in the context of left‑right (LR) asymmetry. These events lead to the formation of three distinct regions, the foregut, midgut and hindgut. All the above‑mentioned phenomena are under strict control from various molecular pathways, which are critical for the normal intestinal development and function. Specifically, the intestinal epithelium constitutes a constantly developing tissue, deriving from the progenitor stem cells at the bottom of the intestinal crypt. Epithelial differentiation strongly depends on the crosstalk with the adjacent mesoderm. Major molecular pathways that are implicated in the embryogenesis of the large intestine include the canonical and non‑canonical wingless‑related integration site (Wnt), bone morphogenetic protein (BMP), Notch and hedgehog systems. The aberrant regulation of these pathways inevitably leads to several intestinal malformation syndromes, such as atresia, stenosis, or agangliosis. Novel theories, involving the regulation and homeostasis of intestinal stem cells, suggest an embryological basis for the pathogenesis of colorectal cancer (CRC). Thus, the present review article summarizes the diverse roles of these molecular factors in intestinal embryogenesis and related disorders.

Malrotation of the midgut associated with horseshoe kidney presenting as gastric outlet obstruction in a 15-year-old boy

Malrotation occurs in approximately 1 in 500 live births. However, the true incidence of malrotation is unknown since many asymptomatic patients fail to present. Approximately 90% of patients with malrotation are diagnosed within the 1^st year of life. Eighty per cent of them are diagnosed within the 1^st month of life. Nevertheless, there are recent reports of manifestations later in life both as emergency conditions and more chronic gastrointestinal symptoms. The relationship between malrotation and horseshoe kidney has not been fully understood, but few case reports have highlighted their occurrence in the same patient. The mode of presentation of this case and its association with a horseshoe kidney is the reason for this report. This was a case of malrotation associated with horseshoe kidney. He had exploratory laparotomy and Ladd's procedure. Malrotation is associated with horseshoe kidney which presented as gastric outlet obstruction. He responded well to treatment after Ladd's procedure.

Presentation of intestinal malrotation and midgut volvulus in adults: Case report & literature review

INTRODUCTION

Malrotation is considered a newborn disease. This case report sheds light on the rare, but possible late presentation of malrotation in adulthood, which if missed, can leave the patient in a detrimental state.

PRESENTATION OF CASE

28-year-old female presented in critical state with acute abdomen. Computed tomography abdomen/pelvis showed midgut volvulus, requiring urgent laparotomy. The patient's bowels were discolored, yet they normalized upon detorsion, except for a small portion, which was equivocal and left for observation. Ladd's bands were excised, and the abdomen was closed with Bogota bag for re-exploration. The patient underwent two more laparotomies to observe the intestinal segment until it was back to normal. Ladd procedure was then completed, and an absorbable mesh was applied. Follow-up of 20 months has been uneventful, except for a small, asymptomatic, incisional hernia.

DISCUSSION

Malrotation in adults is often missed due to its subacute, nonspecific presentation. It is often diagnosed by CT abdomen, which shows inversion or vertical positioning of the superior mesenteric vessels. Symptomatic, but stable patients, can undergo laparoscopic Ladd procedure, which carries the benefit of less length of stay. While an incidental malrotation can be prophylactically operated on, correcting asymptomatic malrotation beyond age of 20 is ineffective and possibly harmful.

CONCLUSION

Intestinal malrotation presenting in an adult should be on the differential diagnosis when dealing with abdominal pain, especially in the context of small bowel obstruction in a virgin abdomen. It is vital to consider a patient's age prior to prophylactically operate on malrotation discovered incidentally.

Unusual intraoperative finding of abnormal retroperitoneal ileum: a case report

A 52-year-old female patient diagnosed with an adenocarcinoma of the sigmoid colon underwent anterior resection with direct anastomosis. Intraoperatively, we found the ileum completely retroperitonealized. Previously, the patient was asymptomatic and no congenital syndromes were diagnosed. The intraoperative finding of abnormal anatomy made the mobilization of the left hemicolon and the vessel ligation more challenging. This anatomical situation is a rare variation due to an embryonic malrotation, which occurs in about 1:500 newborns.

INTESTINAL MALROTATION IN 35 YEAR OLD WOMEN FROM PESHAWAR, PAKISTAN

Thirty five years old women presented to the Accident and Emergency Department with acute onset right upper quadrant abdominal pain with normal vitals. CT images revealed a malrotation causing midgut volvulus and intestinal obstruction. On emergency exploratory laparotomy, the gut loops showed partial ischemia due to a double twist at the root of mesentery and malrotation of the gut along with the caecum which was mobile coming from left iliac fossa and lying in the right iliac fossa. Duodeno-jejunal junction was identified. The coils of the intestine were untwisted and rotation was corrected. The gut color changed back to normal. She was discharged painless after routine post-operative care.