Surgery: Intestinal Malrotation

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.