MALROTATION

What is malrotation?

Malrotation of the intestines results when the intestinal rotation and fixation that occurs during pregnancy fails to occur. This normally happens in the 4^th and 12^th weeks of fetal life. In the 4^th fetal week, the entire bowel is basically a straight tube with the superior mesenteric artery (SMA). During the course of pregnancy, the bowel rotates in place to the left of the SMA at the ligament of Treitz.

Why is malrotation of concern?

In normal rotation and fixation of the intestines, the bowel has plenty of room to function normally. In malrotation, the primary concern becomes volvulus, or twisting of the intestine that causes obstruction and death to that part of the gut (pictured below). Accidental bodily movements, unusual effort, abnormal peristaltic movement (digestive wavelike motion of the intestines) or distention of the intestine can bring on this volvulus.

How is malrotation diagnosed?

The major symptoms of malrotation are bilious vomiting, abdominal pain and abdominal distention. All of these are signs of the intestinal obstruction that has occurred. The bowel twists causing pain; becomes distended (enlarged) because of the pressure and the child will vomit the bile that is released for normal digestion.

X-rays of the abdomen will show air in the stomach and lower in the intestine past the obstruction without air being present anywhere else. Further testing that can occur is a barium swallow that will show the barium coming to a stop at the point of the obstruction. A barium enema will show the location of obstruction and, more clearly, the malrotation as the colon is visualized.

How is malrotation treated?

A child with volvulus is usually dehydrated and has a rapid heart rate. IV fluids will be needed immediately with antibiotics. A nasogastric tube will be placed through the child’s nose into the stomach to decompress or allow the fluids backing up into the stomach to empty. An exploratory laparotomy (surgery) will be performed to take a look at the bowel. The bowel will be detorsed (unwound) and checked carefully (see pictures). The bowel that turns pink (showing returned circulation) after torsion is good bowel. If all bowel turns pink, a Ladd’s procedure will be performed to put the bowel in place to prevent another volvulus. An appendectomy is usually done since the appendix will not be located in the normal area in the abdomen. This could lead to confusion and delay in diagnosing appendicitis in the future.

If there is a question about the bowel’s viability, the abdomen will be left open and a second-look procedure will be planned within 24 to 48 hours.

If there is a section of necrotic (dead) bowel a colostomy may be needed temporarily. The ostomy nurse will consult with you on ostomy care.