Intestinal malrotation — radiology and surgery medical library hypoxic brain damage symptoms

During the 2nd month of embryonic life, intestinal loops rotate in the yolk stalk outside the abdomen around the axis of the superior mesenteric artery. The duodenojejunal loop grows faster than the distal loop which facilitates its rotation of 90° anticlockwise. After the 2nd month, the duodenojejunal loop returns to the abdomen and rotates for additional 180° anticlockwise.

Nonrotation results after the return of the bowel loops to the abdomen which leads to the abnormal location of the colon to the left of the abdomen and the small bowel to the right. It is usually asymptomatic and discovered accidentally with imaging studies. Diffuse axonal brain injury treatment during malrotation, the cecocolic loop rotates for 90° leading to fixation of the cecum in the mid-upper abdomen with peritoneum that can cause intestinal obstruction.

Clinical picture of pediatric intestinal malrotation acute intestinal obstruction

Malrotation can present itself with acute intestinal obstruction or insidious onset of chronic symptoms in older children. The symptoms of acute intestinal obstruction can be bilious vomiting, abdominal pain and distension, hypovolemia and sometimes peritonitis. Chronic symptoms of malrotation include abdominal pain, vomiting, chronic diarrhea, failure to thrive, biliary stones and pancreatitis. Symptoms

Pathogenesis occurs during the embryonic development, due to a rapid growth of the intestine and abdominal contents more than the abdominal cavity leading to physiologic midgut herniation. It becomes smaller and the abdominal contents protrude into the extraembryonic coelom at the base of the umbilical cord. Physiologic midgut herniation is evident at the 9th to 11th-week post-menstrual which should be reduced into the abdominal cavity by the 12th week. It is associated with nonrotation of the intestine and considered a rotational anomaly.

The first imaging modality of choice is plain abdominal radiographs. It is used in stable patients to exclude intestinal perforation and pneumoperitoneum. Severe anoxic brain injury survivor stories the gasless abdomen is common in infants with volvulus. Anxiety disorder nhs double bubble sign indicated duodenal obstruction while passage of a nasogastric tube to the abnormal position of the duodenum is diagnostic. GI contrast series

Plain X-ray is followed by upper GI contrast series which is more accurate and sensitive. Upper GI contrast series is definitive in the diagnosis malrotation as the misplaced duodenum, corkscrew duodenum, volvulus with the beaking duodenum and duodenal atresia. Small bowel follow-through, barium enema, and laparoscopy can be used in cases where the upper GI contrast series are not conclusive. Ultrasonography is also limited in the diagnosis, but it can be used for screening with abnormal positions of the third part of the duodenum, superior mesenteric artery, and vein. CT scan

Whirlpool sign and dilated duodenum also can be visualized in the case of volvulus. CT scan is rarely used for the diagnosis of intestinal malrotation due to limited diagnostic value, but, in specific cases, it can be beneficial e.G. Whirlpool sign in the case of volvulus due to the twisting of the bowel mesentery around the superior mesenteric artery. MRI is useful for pregnant patients and in-utero diagnosis due to when the ionizing radiation is contraindicated. Que es anoxia neonatal flexible sigmoidoscopy is used in volvulus through the lower GI tract. Differential diagnosis of pediatric intestinal malrotation

Barium study (gastrograffin): used if gases are present in the abdomen which indicates partial obstruction but we can’t identify the definite cause of duodenal obstruction by X-ray, especially as fear of ladd’s bands which may lead to volvulus neonatorum. In ladd’s bands, a barium study will show the duedo-jejunal junction on the right side (instead of the left side).

Symptoms: pain: intermittent (periodic) severe colicky abdominal pain (crying, screaming and drawing legs up). Projectile vomiting following attacks of colic. Initially nonbilious, but becomes bilious as the obstruction persists. Child passes “red current jelly stool” when the ongoing obstruction can compromise circulation causing mucosal ischemia.

Investigations: ultrasound is the method of choice in detecting intussusception (has a sensitivity and specificity of 100%). A positive finding of the “target sign” should prompt immediate enema reduction (air or water-soluble contrast is instilled through the rectum and the pressure successfully reduces most obstructions). Air enemas are preferred because they are typically faster, cleaner, and safer than contrast. Acute necrotizing enterocolitis

Patients presenting with acute intestinal obstruction should be evaluated for signs of shock, sepsis and peritonitis. Hypoxic ischemic encephalopathy grade 3 first aid measures should be implemented to those in shock, including resuscitation with fluids, nasogastric tube decompression, broad spectrum antibiotics and exploratory laparotomy. There is no need for imaging diagnosis in these patients. Imaging diagnosis and surgical intervention

In patients with no emergent symptoms, imaging diagnosis is conducted followed by surgical management to fix the bowel loops and prevent future malrotation. The surgical intervention consists of a division of any bands or adhesions compressing the duodenum, widening of the mesenteric base, appendectomy, exclusion of duodenal obstruction and making adhesions to fix the bowel to the right and the colon to the left to prevent malrotation.