[25] Malrotation and Volvulus Flashcards
What is malrotation?
An abnormality of the bowel that occurs during development where the bowel does not sit properly in the abdomen
When does malrotation most commonly become evident?
When midgut volvulus occurs
What is a volvulus?
A complication of malrotation where the bowel twists on itself, cutting off its own blood supply
When does malrotation occur?
Due to improper development beginning at around the 10th week
How is the bowel supposed to develop at around 10 weeks?
The bowel temporarily moves into the umbilical cord to develop and is supposed to move back into the abdomen at 10 weeks
What goes wrong during development to cause malrotation?
Inappropriate coiling as the bowel moves back into the abdomen
What type of volvulus typically occurs as a result of malrotation?
Midgut (small intestine) volvulus
Who do small gut volvuluses most commonly occur in?
Children
What type of volvulus is more common in adults?
Sigmoid volvulus
What is the radiological sign for a sigmoid volvulus?
Coffee bean sign
How may malrotation present?
- Acute process
- Chornic process
What is the acute process seen in malrotation?
Acute midgut volvulus
When does an acute midgut volvulus usually present?
In the first year of life
How does an acute midgut volvulus usually present?
- Sudden onset bilious emesis
- Diffuse abdominal pain
- Abdominal distension
- Melena/haematemesis
What causes melena/haematemesis to occur?
Intraluminal bleeding due to vascular compromise
What can worsening ischaemia lead to?
Signs of shock
What are the signs of shock?
- Poor perfusion
- Decreased urine output
- Hypotension
- Raised lactate
- Base deficit
What is the chronic process seen in malrotation?
Chronic midgut volvulus
How may chronic midgut volvulus present?
- Recurrent abdominal pain
- Malabsorption syndrome
- Recurrent diarrhoea +/- constipation
- Intolerance of solids
- Obstructive jaundice
- Gastro-oesophageal reflux
What are the blood tests for volvulus and malrotation?
- FBC
- ABG/VBG
- Lactate
- G&S
What imaging investigations are useful in a suspected volvulus?
- Ultrasound
- Upper GI series
- Lower GI series
What will an ultrasound show?
Can diagnose malrotation with/without volvulus
Why is an upper GI series useful?
It is the standard diagnostic test for intestinal malrotation
What is required in a lower GI series?
Contrast enema
When is a lower GI series used?
When an upper GI series cannot define the location of the duodenal-jejunal junction
What are the differentials for malrotation and volvulus?
- Bowel obstruction in the newborn
- Necrotising enterocolitis
- Neonatal sepsis
- Duodenal atresia
- Gastro-oesophageal reflux
How should a volvulus be managed initially?
Medical stabilisation
How may a patient with a volvulus be medically stabilised?
- NG tube
- Correction of fluid and electrolyte losses
- Correction of shock if present
What is the definitive surgical treatment of a volvulus?
Ladd procedure
What does the Ladd procedure involve?
Reduction of the volvulus, division of the mesenteric bands, placing the small bowel on the right, large bowel on the left and an appendectomy
What must be decided after reduction of the volvulus?
Whether parts of the bowel are non-viable
What should happen to grossly necrotic bowel?
Resection
What are the potential complications of a volvulus?
- Short bowel syndrome
- Infection, including wound infections and sepsis
- Persistent GI symptoms
