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    Poster Midgut

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    Muruga Prakash
    An 80-year-old man presented with abdominal pain and was found to have malrotation of the intestine which had gone undiagnosed for many years. A CT scan showed dilated small bowels and abnormal positioning of the mesenteric vessels. Exploratory surgery revealed gangrenous small bowels twisted around the superior mesenteric vessels. Unfortunately, due to the extensive non-viable intestine, no further intervention could be done and the patient succumbed post-operatively. Malrotation presenting in adulthood is rare but can cause chronic abdominal pain or acute obstruction like in this case where the diagnosis was initially missed.

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    Poster Midgut

    Uploaded by

    Muruga Prakash
    60 views1 page
    An 80-year-old man presented with abdominal pain and was found to have malrotation of the intestine which had gone undiagnosed for many years. A CT scan showed dilated small bowels and abnormal positioning of the mesenteric vessels. Exploratory surgery revealed gangrenous small bowels twisted around the superior mesenteric vessels. Unfortunately, due to the extensive non-viable intestine, no further intervention could be done and the patient succumbed post-operatively. Malrotation presenting in adulthood is rare but can cause chronic abdominal pain or acute obstruction like in this case where the diagnosis was initially missed.

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    An 80-year-old man presented with abdominal pain and was found to have malrotation of the intestine which had gone undiagnosed for many years. A CT scan showed dilated small bowels and abnormal positioning of the mesenteric vessels. Exploratory surgery revealed gangrenous small bowels twisted around the superior mesenteric vessels. Unfortunately, due to the extensive non-viable intestine, no further intervention could be done and the patient succumbed post-operatively. Malrotation presenting in adulthood is rare but can cause chronic abdominal pain or acute obstruction like in this case where the diagnosis was initially missed.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    60 views1 page

    Poster Midgut

    Uploaded by

    Muruga Prakash
    An 80-year-old man presented with abdominal pain and was found to have malrotation of the intestine which had gone undiagnosed for many years. A CT scan showed dilated small bowels and abnormal positioning of the mesenteric vessels. Exploratory surgery revealed gangrenous small bowels twisted around the superior mesenteric vessels. Unfortunately, due to the extensive non-viable intestine, no further intervention could be done and the patient succumbed post-operatively. Malrotation presenting in adulthood is rare but can cause chronic abdominal pain or acute obstruction like in this case where the diagnosis was initially missed.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 1

    A Fatal Twist -

    Midgut Volvulus in an Elderly

    Muruga P., Woo S.Y., Shamil S., E.S. Lim., Nor Aishah MA
    Department of Surgery, Hospital Ampang

    ntroduction
    Intestinal malrotation is defined as any deviation from the normal 270° counterclockwise rotation of the midgut during
    embryologic development. Malrotation takes place when normal rotational process and fixation of the intestine fail to take
    place. It has usually been estimated to occur in approximately one in 500 newborns and present within the first month of life in
    64-80% of patients.
    Although mainly a paediatric diagnosis, some patients will present later, even in adulthood, or remain asymptomatic for life.
    Herein, we describe a case of intestinal malrotation causing abdominal pain and acute bowel obstruction in an elderly man.

    Case Report
    An 80 year old male presented with intermittent cramping abdominal pain for the past 10 years. He has series of upper GI scope done which
    reveals peptic ulcer disease and history of laparoscopic cholecystectomy for cholelithiasis.
    He appeared in a distressed condition and physical examination revealed diffuse abdominal tenderness with rigidity. Biochemical data
    showed leucocytosis with metabolic acidosis and high serum lactate. CT scan of the abdomen showed dilated small bowels and the exchange
    position of the mesenteric vessels. Under the suspicion of intestinal obstruction and malrotation of the colon, an exploratory laparotomy was
    carried out immediately.
    Intraoperatively, there were gangrenous small bowels up to proximal transverse colon. The bowel was twisted clockwise at it’s mesentery
    around the root of superior mesentery vessels. There were features of malrotation such as high riding caecum plus a narrow and short
    mesentery root too. However, there was no Ladd’s band seen. In view of extensive non-viable intestine, no further surgical intervention was
    carried out.
    The patient succumbed shortly post operatively.

    “Whirlpool sign” -
    Entire length of midgut was
    Bowel Loop
    gangere, twisted at the
    twisted around
    abnormally narrowed SMA
    mesenteric vessels
    pedicle

    Discussion
    Malrotation of the intestine is usually observed in the neonatal period with Surgery has to be done to prevent recurrence of volvulus. This
    signs of acute intestinal obstruction. In contrast, symptomatic malrotation in mandates counterclockwise detorsion of the midgut volvulus if
    adults is unusual. present, division of Ladd’s bands overlying the duodenum
    Atypical symptoms such as chronic abdominal pain with (bilious) vomiting thereby relieving the obstruction, widening of the narrowed root
    over a period of months or years are typical and may eventually lead to of the small bowel mesentery by mobilizing the duodenum and
    further diagnostics. Diagnosis can even be mistaken for biliary disease or division of the adhesions around the SMA to prevent further
    peptic ulcer disease (as in our patient), irritable bowel syndrome, Crohn’s volvulus. Gangrenous segments should be resected with efforts
    disease or even psychiatric illness. being made to preserve intestinal length.
    Most commonly, the small bowel remains on the right side of the abdomen However, in this case, the whole length of mid-gut is gangrene
    while caecum remains on the left, as a result of the absence of a ligament of which is not compatible with life.
    Treitz. The caecum however, remains attached to the right site of the
    abdominal wall through Ladd’s bands, which is a peritoneal fibrous band.
    These adhesional bands are seen running from caecum to the right lateral Conclusion
    abdominal wall often entrap the descending doudenum causing intermittent Given his acute presentation, operative intervention was the natural

    gastro-intestinal obstruction. trajectory in his management. However, this entity can be challenging

    In older patient with acute abdomen symptoms, CT scan is generally to diagnose in the elderly population and a high index of suspicion
    would facilitate a timely diagnosis.
    performed and considered In cases of malrotation, a contrast enhanced CT
    scan shows an inversion of superior mesenteric artery (SMA) and superior
    mesenteric vein (SMV). The SMV is often situated to the left of the artery or
    rotates around the artery. Other characteristic findings on CT include
    “whirlpool sign” described as swirling appearance of bowel and mesentery

    References
    twisted around the SMA axis.

    1.Rowsom JT, Sullivan SN, Girvan DP. Midgut volvulus in the adult: A complication of intestinal malrotation. J Clin Gastroenterol. 1987; 9: 212–16.
    2. Tamura J, Kuniyoshi N, Maruwaka S, Shiroma J, Miyagi S, Orita H, et al. "Whirl sign" of primary small bowel volvulus. West J Emerg Med. 2014;15:359–360.
    10.5811/westjem.2014.4.20679
    3. Gürleyik E, Gürleyik G. Small bowel volvulus: a common cause of mechanical intestinal obstruction in our region. Eur J Surg. 1998;164:51–55. 10.1080/110241598750004959
    4. Roggo A, Ottinger LW. Acute small bowel volvulus in adults. A sporadic form of strangulating intestinal obstruction. Ann Surg. 1992;216:135–141.

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