Intestinal Malrotation in Adults: A Review

Intestinal Malrotation in Adults: A Review
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Intestinal Malrotation Causes

Intestinl MalrotationIntestinal malrotation occurs predominantly amongst infants, with one out of every 500 infants encountering this condition due to any deviation from the normal 270 degrees counterclockwise rotation of the midgut during embryologic development.

Intestinal malrotation in adults is also common. Research is however not yet conclusive of the exact causes of intestional malrotation in adults. While evidence exists of recurrence of this condition in families, the condition is not associated with any particular gene.

Some probable intestinal malrotation causes in adults include hernias, abnormal scar tissue growth after an abdominal operations, and inflammatory bowel disease (IBD).

Image Credit: wikimedia commons/roxbury-de

Risk Factors of Intestinal Malrotation

While intestinal malrotation as such does not pose any problems, it leads to several complicated and dangerous conditions.

Some of the non life-threatening conditions caused by Intestinal malrotation include:

  • shifting of the small bowel to a predominantly right side of the abdomen
  • displacement of the cecum from its usual position in the right lower quadrant into the epigastrium - right hypochondrium
  • rightward and inferior displacement of the ligament of Treitz

Some of the life threatening conditions caused by intestinal malrotation include:

  • formation of fibrous bands of Ladd’s tissue that causes life threatening obstruction to the duodenum, or the first part of the small interstine
  • a medical emergency condition called volvulus, or a twisting of the bowels on itself, obstructing the mesenteric blood vessels and cutting off blood flow to tissues, causing life-threatening intestinal ischemia
  • internal hernia caused by abnormal peritoneal bands that lead to bowel obstruction and strangulation.

Intestinal Malrotation Symptoms

The most apparent and earliest intestinal malrotation symptoms are pain and cramps caused by

  • inability of the bowel to push food past the obstruction
  • blood tissues dying due to cut-off of blood supply by the condition called volvulus

Another major intestinal malrotation symptoms is vomiting, caused by the obstruction of the small intestine. The vomit might contain bile or resemble feces.

Secondary symptoms of intestinal malrotation in adults include:

  • swollen abdomen
  • diarrhea and/or bloody stools
  • lack of stools
  • rapid heart rate and breathing
  • little or no urine due to of fluid loss

Diagnosis of Inestinal Malrottion

The three major tools to diagnose intestinal malrotation are

The diagnosis includes looking for right-sided jejunal markings and or the absence of stool-filled colon in the right lower quadrant, both of which indicates possible intestinal malrotation. The consumption of barium or some other liquid before x-ray or scan provide clarity to the image and helppin point the location of the blockage.

Treatment of Intestinal Malrotation

The treatment of intestinal malrotation is through a surgery called Ladd’s procedure, named after Dr. William Ladd who pioneered the procedure.

The two major pre-operative treatment are

  • insertion of nasogastric (NG) tube through the nose and down into the stomach to remove the contents of the stomach and upper intestines, and keep fluid and gas from building up in the abdomen.
  • administration of intravenous (IV) fluids to prevent dehydration and provide antibiotics to prevent infection. Such IV might continue for some time even after surgery.

The actual surgery entails the following procedures:

  • straightening the intestine
  • dividing and cutting off the Ladd’s bands
  • folding the small intestine to the right side of the abdomen
  • placing the colon on the left side
  • most surgeons remove the appendix to prevent future complications

Critical conditions such as volvulus, Ladd’s tissue, or internal hernia requires emergency surgery.

Extreme cases of intestinal maltrotation might require a second surgery within 48 hours of the first, if blood does not flow properly to the intestines. If the condition still does not improve, the situation might call for removal of the damaged portion of the bowel.