CASE PRESENTATION

Dr akshay gursale

History and clinical

examination

A 10 yr old female patient comes

to casualty with complaints of

pain in epigastric region which was

acute in onset since 2-4 days

Bilious vomiting since 2-4 days

A lump was felt in the epigastrium

with localised tenderness

Temperature was slightly raised

Rest parameters were within normal

limits

Plain X Ray AP View

Doppler on ultrasound

SMV

SMA

Barium study showed the following images

Pylorus and

duodenal bulb

noted to the

right

Direction of

barium flow

The direction

of barium

flow

NGT in

situ

A NORMAL BARIUM STUDY

OUR PATIENT

NORMAL

BARIUM

STUDY

LATERAL

VIEW

OUR PATIENT

BARIUM STUDY

LATERAL VIEW

Pylorus

Duodenal

bulb

DJ

flexure

Jejunal

loops

showing

swirling

pattern

Following barium studies and Ultrasound findings a diagnosis of Malrotation of Gut with Midgut volvulus was made.

Final diagnosis

Pedicel of the

volvulus

operative

Superior

mesenteric artery

noted along the

pedicel

Mesenteric

attachment of

the pedicel

Segment of

intestine along

the volvulus

Operative picture after

the diagnosis was

made which showed

the volvulus at the SMA

TAKE HOME MESSAGE

Upper gastrointestinal barium studies are not

obsolete

One can make a FINAL DIAGNOSIS

on base of sonography and barium studies

alone

Compare with normal

appearances of upper GI barium

series to diagnose MALROTATION

MIDGUT VOLVULUS

EMBRYOLOGY OF ROTATION OF GUT

Gut develops from yolk sac which is further divided into 3 parts

Foregut supplied by Coeliac trunk upto mid 1/3 of duodenum

Midgut supplied by superior mesenteric artery uptodistal transverse colon

And hindgut supplied by inferior mesenteric artery upto anal canal

The intestine upto 4 weeks is a straight tubular structure

By 12weeks it grows rapidly by some complex steps involving a rotation of 270 degrees and fixation in normal position in abdomen

First duodenum rotates 90 deg counterclockwise to the right of SMA while colon 90 deg to the left of SMA

Then midgut herniated through umbilical cord and duodenum go another 90 deg counterclockwise rotation but colon undergoes no rotation

By 10 week the bowel returns to the abdominal cavity and the duodenum undergoes the final 90 deg counterclockwise rotation until duodeno-jejunal junction is to the left of spine and the colon rotates by 180 deg until the caecum is in right lower quadrant

This rotation produces a long mesenteric attachment for the bowel

Salient features of rotation of gut Duodenum describes the c loop with

concavity to patients left and the third part of duodenum to left of midline

SMA runs in front of 3rd part of duodenum

The mesentery run along posteriorly from the ligament of trietz in left upper quadrant to caecum in right lower quadrant preventing its torsion

The ascending colon is fixed in right side of abdomen and desending colon in left side of abdomen

Malrotation is usually daignosed in upto 75% cases in newborns and upto 90% cases by 1st

year

In individuals with malrotation, the mesenteric attachment of the midgut, particularly the portion from the duodenojejunal junction to the cecum, is abnormally short and is therefore prone to twist counterclockwise around the superior mesenteric artery and vein.

This condition, known as midgut volvulus, may cause intermittent abdominal distention and pain or acute bowel necrosis.

Duodenal bulb with DJ to the right

Jejunal loops to the right

Stomach to the right

Concavity of C loop to the right

Stomach to left

Duodenal bulb to right

DJ flexure to left

DJ inferior to duodenal bulb

The normal position of the duodenojejunaljunction is to the left of the left-sided pedicles of the vertebral body at the level of the duodenal bulb on frontal views and posterior (retroperitoneal) on lateral views.

In children with acute duodenal obstruction, the upper GI series may depict a Z-shaped configuration of the duodenum in the presence of obstructing peritoneal bands or a corkscrew-shaped duodenum in the presence of volvulus .

In children who have bowel malrotation without volvulus, the upper GI series shows an abnormal position of the duodenojejunal junction and of the ligament of Treitz

DJ flexure with duodunalbulb to right

Duodenal bulb with jejunalloops to right

Proximal dilated stomach

Crockscrew appearance of duodenum

Normal position of duodenal bulb and c loop of duodenum

Abnormal position of DJ flexure