00:01
Welcome back.
00:02
Thanks for joining me
on this discussion of intestinal malrotation
in the section of pediatric surgery.
00:11
Let's visit the embryology of the GI tract.
00:14
The GI tract (or gastrointestinal tract)
is usually divided into three segments.
00:19
Embryologically,
they represent the foregut,
the midgut
and the hindgut.
00:26
The foregut is generally proximal
to the ligament of Treitz.
00:34
For embryologic reasons,
the GI tract needs to herniate
out of the abdominal cavity.
00:41
That's because there's not enough room
for the rotation to occur inside.
00:45
When the GI tract herniates out,
it actually rotates 270°.
00:52
And the duodenojejunal junction
and the cecal attachments
form after the rotation
and subsequent reattachment
into the abdomen.
01:02
This is what we know
as a normal rotation.
01:07
However,
a malrotation,
as you see on the
right side of the screen,
duodenojejunal and cecal attachments
do not occur in the normal places.
01:20
Midgut volvulus generally presents
itself as bilious emesis,
diffuse abdominal pain
and usually a surgical emergency.
01:29
That makes sense.
01:30
When the intestines are twisted on itself,
it can actually cut
off its blood supply.
01:35
In this surgical image,
you notice that the bowel proximal
and distal to the loop of volvulus
is actually distended.
01:46
What would the babies look like
and their classic physical findings?
Babies may have distended abdomens.
01:54
There may be skin
discoloration if it's late.
01:56
Again, when there are
ischemic bowel changes,
the skin may actually
turn a little bit red.
02:02
And babies may actually
have guarding and drawn up knees.
02:06
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.
02:18
What might you find on routine laboratory?
In a chemistry,
you could find low sodium,
low chloride
and low bicarb.
02:27
And on a CBC,
one might find
an increased white blood
cell count or leukocytosis.
02:35
Here are some representative abdominal x-rays
demonstrating potential findings of malrotation.
02:41
Unfortunately,
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.
02:54
Upper GI series are incredibly helpful.
02:57
Upper GI series,
such as this one and this one,
demonstrate the abnormal attachments
of the duodenal junction
as well as the cecum.
03:09
In these series,
you will notice that the duodenal junction
is on the right side of the spine
as opposed to the left side.
03:16
Remember,
the ligament of Treitz in normal anatomy
is on the left side of the spine.