Intestinal malrotation in children

Types of Intestinal Malrotation

Nonrotation: Bowel returns to coelom.It fails to rotate.Result will be Small bowel to the right & Colon to the left

 

Reversed rotation:It is rare anomaly.There is 90 clockwise rotation around SMA, as a result of which Cecum & transverse colon comes dorsal to SMA while duodenum anterior to SMA

 

Incomplete rotation: There is premature arrest of normal rotation so that Ladd’s bands forms causing duodenal obstruction.Base of the mesentery is narrow  which can cause to clockwise rotation.

Clinical features: 

The newborn presented with bilious vomiting, haematemesis & haematochezia.

In older children, Either they wll be asymptomatic or intermittent abdominal complaints or acute obstructive symptoms &
  signs of impending abdominal catastrophe.

Diagnosis: 

A.X-ray abdomen in erect position- 1.Paucity of gas in the X-ray abdomen 2. Only gastric air-fluid level seen or there will double bubble appearance.

 

B. Upper GI studies:1.Right-sided DJ junction 2. proximal jejunal loops 3. Dilated stomach s/o incomplete obstruction of the duodenum.
4. Midgut volvulus - Corkscrew appearance.

 

C.Ultrasound doppler: There will be either vertical orientation or left-right inversion of SMA & SMV.

 

D.CT Scan of the abdomen: 1.Alteration of SMA & SMV orientation. 2. DJ & small bowel loops seen on right side of the spine. 3. large bowel is seen on left side of the abdomen. 4. there will be signs s/o duodenal obstruction.

Management: Ladd's procedure.Step 1.- lysis of ladd's bands & many other adhesivebands. 2.Mesenteric base widening 3. straightening of duodenum. 4. appendicectomy 5. Placing small bowel on right side of abdomen while large bowel on the left side of the abdomen.