Intestinal Mal-rotation in an adult male: case report and literature review

Author(s)

Dr. Marlon D. Brown MD, MPH ,

Download Full PDF Pages: 01-08 | Views: 1054 | Downloads: 242 | DOI: 10.5281/zenodo.3445845

Volume 6 - October 2017 (10)

Abstract

Introduction: intestinal mal-rotation is widely considered paediatric pathology where the vast majority of presentation would occur. In the paediatric population this condition has an incidence rate of about 1 in 500 live births (7) in which 75% to 85% of these are diagnosed within infancy. The adult population presentation is an increasing form in which in several studies conducted by Nehra et al, and Kotobi et al, and have shown a prevalence rates of 48% (1) and42% (2) respectively. Although according to other studies the true incidence in the adult population is difficult to calculate (23). This is partially due to the fact that a significant proportion may remain asymptomatic throughout their lives (24) and the rest are diagnosed intra-operatively during other procedures or at autopsy (25).

Method: This case of a 36 year old male patient well-nourished and average height was hospitalised with a presenting complaint of abdominal pain for one day. This patient had a Past medical history of asthma with the last attack a week prior to this presentation. On physical examination was found to be afebrile and haemodynamically stable. The abdominal findings were distension and generalised tenderness. There were no mass or organomegally on palpation however there was brown stool and scant blood on digital rectal examination. A nasogastric tube was sited. The urinary catheter was not cited as this patient had urethral strictures. Strict input and out charting were done along with timely monitoring of vital signs. The laboratory investigations were found to be within normal range. The abdominal radiographic findings were multiple air fluid levels on erect view and dilated loops of bowel on the supine view.

Results: This patient was resuscitated with intravenous fluid therapy, analgesia, prophylactic antibiotic along with deep vein thrombosis prophylaxis and booked for exploratory laparotomy. Intra-operatively Ladd’s bands with a mal-rotated intestine were found. Ladd’s procedure and supra-pubic cystostomy were done. The patient had an uneventful postoperative period and was discharged home on day 5th post-op with regular surgical outpatient follow up.

Conclusion: This late presentation of a congenital pathology such as intestinal mal-rotation can be a diagnostic and therapeutic challenge. Therefore the need to include this as an armament in the diagnostic differentials in an adult with vague abdominal complaint is essential to avoid any surgical catastrophe. The Ladd’s procedure is the current gold standard.

Keywords

Mal-rotation, Intestinal volvulus, Ladd’s procedure

References

           i.            Nehra D, Goldstein AM. Intestinal malrotation: varied clinical presentation from infancy through adulthood. Surgery. 2011 Mar. 149(3):386-93. [Medline].

         ii.            Kotobi H, Tan V, Lefèvre J, Duramé F, Audry G, Parc Y. Total midgut volvulus in adults with intestinal malrotation. Report of eleven patients. J Visc Surg. 2016 Nov 22. [Medline].

       iii.            Von Flue M, Herzog U, Ackermann C, et al: Acute and chronic presentation of intestinal nonrotation in adult. Dis Colon Rectum 1994, 37:192-198.

       iv.            Wang C, Welch C: Anomalies of intestinal rotation in adolescents and adults. Surgery 1963, 54:839 855.

         v.            Dietz DW, Walsh RM, Grundfest-Broniatowski S, Lavery IC, Fazio VW, Vogt DP: Intestinal Malrotation: a rare but important cause of bowel obstruction in adults. Dis Colon Rectum 2002, 45(10):1381-1386.

       vi.            Ladd WE: Surgical diseases of the alimentary tract in infants. N Engl J Med 1936, 215:705708.

     vii.            Torres AM, Ziegler MM: Malrotation of the intestine. World J Surg 1993, 17:326-331.

   viii.            Fu T, Tong WD, He YJ, Wen YY, Luo DL, Liu BH: Surgical management of intestinal malrotation in adults. World Journal of Surgery 2007, 31:1797-1803.

       ix.            Matzke GM, Moir CR, Dozois EJ: Laparoscopic Ladd procedure for adult malrotation of the midgut with cocoon deformity: report of a case. J Laparoendosc Adv Surg Tech A 2003, 13:327329.

         x.            Matzke GM, Dozois EJ, Larson DW, Moir CR: Surgical management of intestinal malrotation in adults: comparative results for open and laparoscopic Ladd procedures. Surg Endosc 2005, 19:1416-1419.

       xi.            Moldrem AW, Papaconstantinou H, Broker H, Megison S, Jeyarajah DR: Late presentation of intestinal malrotation: an argument for elective repair. World J Surg 2008, 32:1426-1431.

     xii.            . Pickhardt PJ, Bhalla S: Intestinal malrotation in adolescents and adults: spectrum of clinical and imaging features. American Journal of Radiology 2002, 179:1429-1435

   xiii.            Pacros JP, Sann L, Genin G, Tran-Minh VA, Morin de Finfe CH, Foray P, Louis D: Ultrasound diagnosis of midgut volvulus: the „whirlpool‟ sign. Paediatr Radiology 1992, 22:18-20.

    xiv.            Nichols DM, Li DK: Superior mesenteric vein rotation: a CT sign of midgut malrotation. Am J Roentgenol 1983, 141:707-708.

      xv.            Fisher JK: Computer tomographic diagnosis of volvulus in intestinal malrotation. Radiology 1981, 140:145-146.

    xvi.            Hsu CY, Chiba Y, Fukui O, Sasaki Y, Miyashita S: Counterclockwise barberpole sign on prenatal three-dimensional power Doppler sonography in a case of duodenal obstruction without intestinal malrotation. J Clin Ultrasound Feb 2004, 32(2):86-90.

  xvii.            Badea R, Al Hajjar N, Andreica V, Procopet B, Caraiani C, Tamas-Szora A: Appendicitis associated with intestinal malrotation: imaging diagnosis features. Case report. Med Ultrason 2012, 14:164–167.

xviii.            Bax NM, van der Zee DC: Laparoscopic treatment of intestinal malrotation in children. Surg Endosc 1998, 12(11):1314-1316.

    xix.            Kalfa N, Zamfir C, Lopez M, Forgues D, Raux O, Guibal MP, Galifer RB, Allal H: Conditions required for laparoscopic repair of subacute volvulus of the midgut in neonates with intestinal malrotation: 5 cases. Surg Endosc 2004, 18:1815-1817.

      xx.            Stanfill AB, Pearl RH, Kalvakuri K, Wallace LJ, Vegunta RK: Laparoscopic Ladd’s Procedure: Treatment of Choice for Midgut Malrotation in Infants and Children. J Laparoendosc Adv Surg Tech A 2010, 20(4):369-372.

    xxi.            Spigland N, Brandt ML, Yazbeck S. Malrotation beyond the neonatal period. J PediatrSurg 1990;25:1139-1142.

  xxii.            Mazziotti MV, Strasberg SM, Langer JC. Intestinal rotation abnormalities without volvulus: the role of laparoscopy. J Am CollSurg 1997;185:172-176.

xxiii.            Andrassy RJ, Mahour GH. Malrotation of the midgut in infants and children. Arch Surg. 1981;1 16:158-60.

xxiv.            Gamblin TC, Stephens RE, Johnson RK, et al. Adult malrotation: a case report and review of literature. Curr Surg 2003; 60:517-20.

  xxv.            Wright JK, Roesel JF, Lopez RR. Malrotation of the intestine in adulthood. J Tenn med assoc 1994;87:141-5

xxvi.            El-Gohary Y, Alagtal M, Gillick J. (2010). Long-term complications following operative intervention for intestinal malrotation: a 10-year review. Pediatr Surg Int 26:203–206

xxvii.            Freitz R, Vos A (1997) Malrotation: the postoperative period. J Pediatr Surg 32(9):1322–1324

xxviii.            Hota PK, Abhishek D, Bhaskar V. Adult midgut malrotation with ladd’s band:  a rare case report with review of literatures. Bali Med J 2014; 3: 137-142

xxix.            Dott NM. Anomalies of intestinal rotation: their embryology and surgical aspects with reports of five cases. Br J Surg. 1923; 251–286.

  xxx.            Kiesewetter WB, Smith JW. Malrotation of midgut in infancy and childhood. Arch Surg. 1958;77:483–491.

Cite this Article: