Intestinal malrotation

For those with intestinal malrotation, the anatomic variant that poses the highest risk of volvulus is a narrow midgut mesenteric base accompanied by lack of retroperitoneal midgut fixation. This variant cannot be reliably determined from any radiologic studies.

Malrotation predisposes patients to a risk of midgut volvulus.

The presence of bilious (dark green) vomiting is a key factor in considering the possibility of midgut volvulus. Prompt discussion with a pediatric surgeon is advised in this scenario to ensure timely referral, investigation, and management.

Emergency surgical consultation is appropriate before obtaining any diagnostic studies if midgut volvulus is suspected. Upper gastrointestinal contrast studies should be ordered in patients who are stable.

Treatment is surgical correction, the procedure of choice being a Ladd procedure.

Intestinal malrotation is a term used to describe an entire spectrum of rotational and fixation disturbances that can occur during embryonic development.

The most significant pathologic concerns in malrotation are a lack of intestinal fixation to the retroperitoneum and a narrow midgut mesenteric base that predisposes to a twisting of the small bowel in the form of midgut volvulus. This creates an abrupt obstruction of the duodenum, resulting in bilious (dark green) vomiting. [Figure caption and citation for the preceding image starts]: Malrotation with volvulus causing complete obstruction of the duodenum that does not sweep to the left, as seen on upper GI contrastFrom the collection of Dr S.D. St Peter [Citation ends].

If the twisting at the base also obstructs flow in the superior mesenteric artery, the entire small intestine and proximal colon may become acutely ischemic and subsequently necrotic within a few hours. Abnormal cecal attachments to the right upper peritoneal cavity (i.e., Ladd bands) can cross the second portion of the duodenum creating an extraluminal low-grade obstruction of the duodenum, which may present with signs of partial obstruction.

Patients with malrotation are at risk for volvulus and should be identified whenever possible to allow for proper therapy.