Midgut malrotation: case series

Mal rotation of midgut is associated with other anomalies usually encountered in neonatal period or early childhood. If undetected in childhood it presents in adulthood with small bowel obstruction, repeated appendicitis or chronic abdominal symptoms. CECT abdomen is mandatory for diagnosis though it often presents as surgical surprise on abdominal laparotomy. Hereby, we presented 3 cases where it was undetected till adulthood though CECT was mandatory for definitive diagnosis. Case 1 patient presented with chronic abdominal pain on left abdomen was actually malrotation with appendix lying on left hypochondrium and stenosed fourth part duodenum adding to vomiting off and on. Case 2 patient in adulthood presented with repeated sub-acute intestinal obstruction because of midgut mal-rotation. Relieved after Ladd band was cut and obstructive symptoms relieved. Case 3 patient had inflammed appendix in subhepatic position was cause of chronic pain with para duodenal hernial sac adding to intestinal obstruction with malrotation of midgut.

Ultrasound for the diagnosis of malrotation and volvulus in children and adolescents: a systematic review and meta-analysis

ContextDespite the advantages of ultrasound (US), upper gastrointestinal contrast series (UGI) remains the first-line diagnostic modality in the diagnosis of midgut malrotation and volvulus in children.ObjectiveEvaluate the diagnostic accuracy of US in the diagnosis of malrotation with or without volvulus in children and adolescents aged 0–21 years, compared with the reference standard (diagnosis by surgery, UGI, CT, MRI, and clinical follow-up individually or as a composite).Data sourcesWe searched the electronic databases Ovid-MEDLINE, Embase, Scopus, CINAHL, and the Cochrane library in October 2019 and updated on 18 August 2020.Study selectionStudies evaluating the diagnostic performance of US for diagnosis of midgut malrotation with or without volvulus in children (0–21 years).Data extraction and synthesisThe data were extracted independently by two authors and a bivariate model was used for synthesis.ResultsMeta-analysis of 17 cohort or cross-sectional studies and 2257 participants estimated a summary sensitivity of 94% (95% CI 89% to 97%) and summary specificity of 100% (95% CI 97% to 100%) (moderate certainty evidence) for the use of US for the diagnosis of malrotation with or without midgut volvulus compared with the reference standard. Subgroup analysis and meta-regression revealed better diagnostic accuracy in malrotation not complicated by volvulus, in the neonatal population and enteric fluid administration before US.ConclusionsModerate certainty evidence suggests excellent diagnostic accuracy and coupled with the advantages, a strong case exists for the use of abdominal US as the first-line diagnostic test for suspected midgut malrotation with or without volvulus in children and adolescents.

Midgut malrotation with volvulus discovered at an emergency caesarean section for placental abruption

Adult midgut malrotation with volvulus (AMMV) is an uncommon presentation which may be found incidentally during abdominal radiologic investigations or at laparotomy. We report a case of AMMV and small bowel gangrene in a 35-year-old Gravida four, Para three at 39 weeks, 4 days gestation who presented with a short history of worsening abdominal pain, repeated vomiting and abdominal wall guarding. Emergency caesarean section performed on account of a suspected placental abruption incidentally revealed a long segment of non-viable small intestine. Subsequent midline laparotomy disclosed a midgut malrotation with volvulus and bowel gangrene. This resulted in a 4.6m resection of non-viable small bowel with Ladd’s procedure. The patient developed moderate symptoms of short bowel syndrome in the post-operative period which was successfully managed non-operatively. This case report represents a rare diagnosis, in the West-African sub-region, of an adult midgut malrotation with volvulus mimicking a third trimester obstetric emergency.