Barber Pole Sign in CT Angiography, Adult Presentation of Midgut Malrotation: A Case Report

Midgut malrotation: a rare presentation of bowel obstruction in the adult

Intestinal malrotation is a rare congenital abnormality. Usually, patients with malrotation of the intestine present in the neonatal period or the first year of life while some may remain asymptomatic and present later in childhood or adulthood. The diagnosis is usually delayed due to the sequence of events being that of non-specific gastrointestinal symptoms, which culminates in either adhesive bowel obstruction or volvulus. A 59-year-old male diagnosed with a large, incarcerated, right inguinoscrotal hernia underwent emergency laparotomy, which revealed midgut malrotation and small bowel obstruction due to Ladd bands. A modified Ladd’s procedure and right inguinal herniorrhaphy was performed.

Ligament of Treitz: Anatomy, Relevance of Radiologic Findings, and Radiologic-Pathologic Correlation

OBJECTIVE. The objective of this article is to discuss the anatomy, embryonic origin, normal variants, and various attachments of the ligament of Treitz. We also describe the pathologic processes that develop along the ligament of Treitz and the role of cross-sectional imaging in identifying these conditions. CONCLUSION. The ligament of Treitz, also known as the suspensory ligament of the duodenum, is an important anatomic landmark in the abdomen. It is essential that radiologists understand the anatomic attachments, normal variants, and various pathologic conditions involving the ligament of Treitz as well as the role of cross-sectional imaging in the assessment of these conditions.

Adult Presentations of Congenital Midgut Malrotation: A Systematic Review

BACKGROUND

Adult midgut malrotation is a rare cause of an acute abdomen requiring urgent intervention. It may also present in the non-acute setting with chronic, non-specific symptoms. The objective of this study is to identify the clinical features, appropriate investigations and current surgical management associated with adult malrotation.

METHODS

A systematic review was conducted according to PRISMA guidelines, identifying confirmed cases of adult malrotation. Patient demographics, clinical features, investigation findings and operative details were analysed.

RESULTS

Forty-five reports met the inclusion criteria, totalling 194 cases. Mean age was 38.9 years (n = 92), and 52.3% were male (n = 130). The commonest presenting complaints were abdominal pain (76.8%), vomiting (35.1%) and food intolerance (21.6%). At least one chronic symptom was reported in 87.6% and included intermittent abdominal pain (41.2%), vomiting (12.4%) and obstipation (11.9%). Computerised tomography scanning was the most frequent imaging modality (81.4%), with a sensitivity of 97.5%. The whirlpool sign was observed in 30.9%; abnormalities of the superior mesenteric axis were the commonest finding (58.0%). Ladd's procedure was the most common surgical intervention (74.5%). There was no significant difference in resolution rates between emergency and elective procedures (p = 0.46), but length of stay was significantly shorter for elective cases. (p = 0.009). There was no significant difference in risk of mortality, or symptom resolution, between operative and conservative management (p = 0.14 and p = 0.44, respectively).

CONCLUSION

Malrotation in the adult manifests with chronic symptoms and should be considered as a differential diagnosis in patients with abdominal pain, vomiting and food intolerance.

Cinematic rendering of small bowel pathology: preliminary observations from this novel 3D CT visualization method

3D visualization methods for volumetric CT data have played an important role in diagnostic imaging of the small bowel, a structure which intrinsically crosses numerous slices in any 2D imaging plane. Recently, a new approach to 3D CT image creation has become available-cinematic rendering (CR). CR differs from other 3D methods in making use of a global lighting model that produces high surface detail and realistic shadowing effects that lead to 3D visualizations with photorealistic quality. Although the utility of these images for improving diagnostic accuracy has not yet been established, our group's early experience in regions of complex anatomy and pathology has been encouraging. In this pictorial review, we review the established role of 3D CT in many of the most common small bowel pathologies, provide examples of those pathologies visualized with CR, and suggest future directions for researchers to pursue.

An unusual presentation of congenital intestinal malrotation in a nonagenarian

INTRODUCTION

Appendicitis is a common surgical pathology with many clinical presentations. Diagnosis can be challenging if there is an alteration to the normal position of anatomical structures and their relationships.

CASE PRESENTATION

In this case, we report an unusual presentation of congenital intestinal malrotation in a nonagenarian presenting with generalized abdominal pain and lactic acidosis found to have perforated appendicitis. The patient was admitted to the Hospitalist service for abdominal pain and misdiagnosed with bowel obstruction secondary to previous "operation". After further review of imaging malrotation with internal hernia was suggested. The patient was taken emergently to the operating room and found to have perforated and gangrenous appendix in the midabdomen. An appendectomy was performed and patient was ultimately discharged home in good condition on postoperative day four.

DISCUSSION

Malrotation of the intestines is a developmental variant that occurs when normal fetal rotation of the intestines around the superior mesenteric artery and their peritoneal fixation fails to occur. Presentation typically occurs during infancy and diagnosis in an elderly patient is exceedingly rare. Operative intervention is often required as it is commonly associated with lactic acidosis or peritonitis.

CONCLUSIONS

Malrotation can go undiagnosed well into elderly life and can present with unusual signs and symptoms. CT is very helpful in aiding the diagnosis but itself can be misleading.