Thanks for joining me
on this discussion of intestinal malrotation
in the section of pediatric surgery.
Let's visit the embryology of the GI tract.
The GI tract (or gastrointestinal tract)
is usually divided into three segments.
they represent the foregut,
and the hindgut.
The foregut is generally proximal
to the ligament of Treitz.
For embryologic reasons,
the GI tract needs to herniate
out of the abdominal cavity.
That's because there's not enough room
for the rotation to occur inside.
When the GI tract herniates out,
it actually rotates 270°.
And the duodenojejunal junction
and the cecal attachments
form after the rotation
and subsequent reattachment
into the abdomen.
This is what we know
as a normal rotation.
as you see on the
right side of the screen,
duodenojejunal and cecal attachments
do not occur in the normal places.
Midgut volvulus generally presents
itself as bilious emesis,
diffuse abdominal pain
and usually a surgical emergency.
That makes sense.
When the intestines are twisted on itself,
it can actually cut
off its blood supply.
In this surgical image,
you notice that the bowel proximal
and distal to the loop of volvulus
is actually distended.
What would the babies look like
and their classic physical findings?
Babies may have distended abdomens.
There may be skin
discoloration if it's late.
Again, when there are
ischemic bowel changes,
the skin may actually
turn a little bit red.
And babies may actually
have guarding and drawn up knees.
Unlike in other infantile
small bowel obstructions,
malrotation is considered
a surgical emergency
and it's usually in babies
who are a little bit older.
What might you find on routine laboratory?
In a chemistry,
you could find low sodium,
and low bicarb.
And on a CBC,
one might find
an increased white blood
cell count or leukocytosis.
Here are some representative abdominal x-rays
demonstrating potential findings of malrotation.
like other small bowel obstructions,
malrotation may demonstrate
itself on abdominal x-rays
simply as distended loops,
as you see on the right side of the screen.
Upper GI series are incredibly helpful.
Upper GI series,
such as this one and this one,
demonstrate the abnormal attachments
of the duodenal junction
as well as the cecum.
In these series,
you will notice that the duodenal junction
is on the right side of the spine
as opposed to the left side.
the ligament of Treitz in normal anatomy
is on the left side of the spine.