Let’s switch gears
This isn’t so much a problem
with the enteric passage itself,
but rather that it’s mislocated
within the abdominal wall.
So, here’s a classic example.
An infant is born three weeks of age,
could be older,
and is brought to the emergency
with bilious or dark green
vomiting and abdominal pain.
He gets an urgent upper
GI contrast study
which shows emptying of stomach
contents into the right lower quadrant
instead of across the
ligament of Treitz.
So bilious emesis in any
baby is concerning.
Abdominal pain, and certainly, when
you see emptying of stomach contents
into right lower quadrant on the upper GI
study, you know this child has malrotation.
So, what’s malrotation?
This is one of the most common causes
of intestinal obstruction in infancy.
It is a surgical emergency.
These children may not go
home and come back later.
This presents as a volvulus.
Fifty percent of these children will
present in their first month of life
and 90% will present in
their first year of life,
although a tiny percent
may present years later.
This is caused by an incomplete rotation of
the gut during embryological development.
Recall your embryology.
The gut actually passes
outside of the child,
twists around and then goes back in again.
If that rotation is incomplete,
this child may have malrotation.
So, what you’ll see when you look
at the child now that they’re born
is the cecum remains high up in the
abdominal compartment and fixed,
attached to the posterior
It’s attached there
by Ladd’s bands,
which are remnants of peritoneum that are
fixing it against the abdominal wall.
These Ladd’s bands now may
obstruct the duodenum
and prevent the passage of
food out past the stomach
through to the duodenum
and into the jejunum.
So, what you can see is these children
will have an abnormal location,
where the dotted lines
are in this film,
and it will be moved up
and the Ladd’s bands will be fixed
there obstructing the duodenum.
Patients with malrotation will have acute,
forceful, and this is key, bilious emesis.
Bilious emesis in a child under one year of
age is malrotation until proven otherwise.
That’s a very important clinical pearl.
These children will absolutely
get small bowel obstruction
and all the compromises
that can happen as a result
sepsis, shock, and death.
Early onset is classic, usually in
the first year of life like we said,
and often in the first month, these
children will get abdominal distention
and they often may present
as bloody diarrhea later
as that intestinal wall is
now desiccating and necrotic
and they’re now bleeding into
their intestinal compartment.
Later onset patients, those rare that
come later, may be asymptomatic.
They may have chronic insidious emesis.
They may have failure to thrive,
anorexia or poor feeding
and they may suffer
So these children are
sometimes harder to detect.
So physical exam findings in
children with malrotation
include that early, they may
be relatively well appearing.
The mom says, “My baby has been
so healthy her whole life."
"I don’t understand why
this is happening.”
The child should have signs of
dehydration, some abdominal distention,
some diffuse abdominal
It’s rare for a baby to be able
to localize their tenderness.
Shock or sepsis is common especially
if there is a delay in diagnosis
or the child has been having symptoms
for many days prior to presentation.
or frankly, bloody stool
is a sign that this has
been going on too long.
So, to make the diagnosis,
any infant with bilious emesis has
malrotation until proven otherwise.
An ultrasound or radiologic
studies are indicated,
and we’ll talk about what those are.
And then, we must do a surgical evaluation
and a surgical correction for this problem.
So the radiologic findings, most
centers are moving towards ultrasound.
An experienced ultrasonographer can
follow the sweep of the intestine
and actually comment on the orientation
of the blood vessels into the intestine.
Keep in mind if a child has
malrotated, essentially, twice,
the orientation of the blood
vessels may still be normal
and then it will require
they followed the sweep
of the intestine.
It’s important to speak
with the ultrasonographer
and determine exactly what they
found in a case like this.
If the ultrasonographer isn’t sure,
we would proceed to an upper GI.
A plain film and an
upright abdominal X-ray
may show distended loops of
bowels with air-fluid levels
but is unlikely to
make the diagnosis.
What you can see here on the right
side of your slide is an upper GI.
And in this case, they did a
small bowel follow-through
that is not necessary
to make this diagnosis.
The green arrow is showing a
corkscrew-like drainage of the duodenum
as it’s failing to cross over the body
and across the ligament of Treitz
onto the left upper quadrant.
So the drainage of the fluid coming
out of the gastric compartment
is going inferiorly instead of
across in a corkscrew-like manner.
This is classic for malrotation.
You can see the duodenal contents
are inappropriately located
in the right lower quadrant instead
of the left upper quadrant.
So, if we suspect the
child has malrotation,
and we’ve shown it either on
ultrasound or an upper GI,
we now have to
manage this patient.
Critical is fluid resuscitation.
These children are usually dehydrated,
and we’ll start with fluid resuscitation
so that they’re stable for surgery.
We will also correct any electrolyte
imbalances that might be happening.
Broad spectrum IV antibiotics will
be indicated for septic patients,
gone on too long.
An example of antibiotics
I might choose are Zosyn,
or you might choose a fourth-generation
cephalosporin and vancomycin.
Generally, very powerful
broad spectrum antibiotics.
Then, we hand these children
over to the surgical team
and they will perform
the Ladd procedure.
This is a resection of the
necrotic portion of small bowel
and a reorientation of the intestinal
contents within the abdominal compartment.
So, potential complications of a
malrotation are necrotic bowel.
If these children need a large
amount of bowel removed,
they will develop short gut
syndrome, which is a real problem
and may require long-term hyperalimentation
resulting in liver failure,
or in worse case scenarios, may
require a small bowel transplant.
Sometimes children, postoperatively,
will develop adhesions
which can then later result in,
again, a small bowel obstruction.