MALROTATION OF GUT
Dr. Narendra Kumar *
Pediatric Surgeon, Rainbow Children's Hospital, Hyderabad *
Malrotation of gut is the result of disruption in the normal embryological development of the gut. Intestinal malrotation can be intestinal non-rotation or incomplete rotation around the superior mesenteric artery. It involves anomalies of intestinal fixation as well. During embryonic development, intestinal rotation primarily occurs in the midgut i.e., the segment supplied by the superior mesenteric artery. So, the normal rotation takes place around the SMA as the axis. It is described by referring to two ends of the alimentary canal the proximal duodeno-jejunal loop and the distal caeco-colic loop. Usually, it is divided into 3 stages (each stage consisting of 90 degrees rotation). Both loops make a total of 270 degrees rotation in counterclockwise direction during normal development. Both loops start in vertical plane parallel to the SMA and end in a horizontal plane. Any disruption of this complex process can lead to malrotation of gut. Intestinal malrotation occurs at a rate of 1 in 500 live births. Malrotation can be an associated finding in patients with duodenal atresia, jejuno-ileal atresia, omphalocele, and congenital diaphragmatic hernia. Clinical features depend on the stage of disruption & interruption of typical intestinal rotation and fixation can occur at a wide range of locations and this leads to a variety of both acute and chronic presentations of the disease. The presentations can be acute midgut volvulus/chronic midgut volvulus, acute duodenal obstructions, chronic duodenal obstructions and internal hemiations. Up to 40% of patients with malrotation present within the 1st week of life. This condition is diagnosed within 50% of patients by age of 1 month. It is diagnosed in 75% by the age of 1 year. The remaining 25% present after age of 1 year and into late adulthood. Upper GIT contrast series is the study of choice. Normal rotation is present, if the C-loop crosses the midline and places the duodeno-jejunal junction to the left of the spine at a level equal to or greater than pylorus. The diagnostic criteria for malrotation are: dilated stomach and duodenum, DJ junction to the left side of the midline, proximal small bowel loops on the right side of the abdomen. In experienced hands, ultrasonography has been shown to be very sensitive (100%) in detecting neonatal malrotation. The diagnostic criteria is the inversion of the relation of SMV and SMA. Volvulus is highly probable if there is coiling of SMV around SMA. CT scan is not recommended as the principal diagnostic tool. Only definitive treatment for malrotation of gut is surgical. It is advised when malrotation is detected at any age. In 1936, William Eladds wrote the classic article on the treatment of malrotation and his surgical approach (i.e., Ladd's procedure) remains the cornerstone of practice today. A classic Ladd's procedure is described as reduction of volvulus (if present), division of mesenteric bands, placement of small bowel on right side and large bowel on the left of the abdomen and appendicectomy. It can be done by open method or laparoscopically. If midgut volvulus presents, the procedure depends on the status of bowel after the volvulus is reduced. The options available are resection and primary anastomosis, resection and enterostomy or resection of frankly gangrenous bowel and wait for second look operation.

Conclusions: Normal rotation of gut is a complex but well understood procedure. Disruption of this process will lead to Malrotation of gut.
  • Presentations depends on the stage of disruption. This leads to a variety of presentations. The presentations can be acute or chronic malrotation of gut has to be excluded in all cases with vague GIT symptoms.
  • Upper GIT contrast study is the diagnostic investigation. Dilated stomach and duodenum, right sided duodeno-jejunal junction, presence of small bowel loops on the right side are diagnostic criteria.
  • Midgut volvulus is the dreaded complication of malrotation of the gut, as the entire midgut will loose its vitality if it surgical intervention is delayed.
  • Surgical intervention remains the definitive treatment of malrotation of gut. It is advised, when malrotation is detected at any age. Ladd's procedure remains as the cornerstone of surgical treatment.
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Kumar N D.. Available From : http://www.pediatriconcall.com/fordoctor/ Conference_abstracts/report.aspx?reportid=205
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