Midgut volvulus

medical

1. Case presentation Dr akshay gursale

2. History and clinical examination A 10 yr old female patient comes to casualty with complaints of pain in epigastric region which was acute in onset since 2-4 days Bilious vomiting since 2-4 days A lump was felt in the epigastrium with localised tenderness Temperature was slightly raised Rest parameters were within normal limits

3. Plain X Ray AP View

4. Doppler on ultrasound SMV SMA

5. WHIRPOOL SIGN

6. Barium study showed the following images Pylorus and duodenal bulb noted to the right Direction of barium flow

7. The direction of barium flow NGT in situ

8. A NORMAL BARIUM STUDY

9. OUR PATIENT

10. NORMAL BARIUM STUDY LATERAL VIEW

11. OUR PATIENT BARIUM STUDY LATERAL VIEW

12. Pylorus Duodenal bulb DJ flexure Jejunal loops showing swirling pattern

13. Following barium studies and Ultrasound findings a diagnosis of Malrotation of Gut with Midgut volvulus was made. Final diagnosis

14. Pedicel of the volvulus operative Superior mesenteric artery noted along the pedicel Mesenteric attachment of the pedicel Segment of intestine along the volvulus Operative picture after the diagnosis was made which showed the volvulus at the SMA

15. TAKE HOME MESSAGE

16. MIDGUT VOLVULUS EMBRYOLOGY OF ROTATION OF GUT Gut develops from yolk sac which is further divided into 3 parts Foregut supplied by Coeliac trunk upto mid 1/3 of duodenum Midgut supplied by superior mesenteric artery upto distal transverse colon And hindgut supplied by inferior mesenteric artery upto anal canal

17. The intestine upto 4 weeks is a straight tubular structure By 12weeks it grows rapidly by some complex steps involving a rotation of 270 degrees and fixation in normal position in abdomen First duodenum rotates 90 deg counterclockwise to the right of SMA while colon 90 deg to the left of SMA Then midgut herniated through umbilical cord and duodenum go another 90 deg counterclockwise rotation but colon undergoes no rotation

18. By 10 week the bowel returns to the abdominal cavity and the duodenum undergoes the final 90 deg counterclockwise rotation until duodeno-jejunal junction is to the left of spine and the colon rotates by 180 deg until the caecum is in right lower quadrant This rotation produces a long mesenteric attachment for the bowel

19. Salient features of rotation of gut Duodenum describes the c loop with concavity to patients left and the third part of duodenum to left of midline SMA runs in front of 3 rd part of duodenum The mesentery run along posteriorly from the ligament of trietz in left upper quadrant to caecum in right lower quadrant preventing its torsion The ascending colon is fixed in right side of abdomen and desending colon in left side of abdomen

20. Malrotation is usually daignosed in upto 75% cases in newborns and upto 90% cases by 1 st year In individuals with malrotation , the mesenteric attachment of the midgut , particularly the portion from the duodenojejunal junction to the cecum , is abnormally short and is therefore prone to twist counterclockwise around the superior mesenteric artery and vein. This condition, known as midgut volvulus , may cause intermittent abdominal distention and pain or acute bowel necrosis.

21. Duodenal bulb with DJ to the right Jejunal loops to the right Stomach to the right Concavity of C loop to the right Stomach to left Duodenal bulb to right DJ flexure to left DJ inferior to duodenal bulb Heterotaxy Syndrome Normal study

22. The normal position of the duodenojejunal junction is to the left of the left-sided pedicles of the vertebral body at the level of the duodenal bulb on frontal views and posterior (retroperitoneal) on lateral views. In children with acute duodenal obstruction, the upper GI series may depict a Z-shaped configuration of the duodenum in the presence of obstructing peritoneal bands or a corkscrew- shaped duodenum in the presence of volvulus . In children who have bowel malrotation without volvulus , the upper GI series shows an abnormal position of the duodenojejunal junction and of the ligament of Treitz

23. DJ flexure with duodunal bulb to right Duodenal bulb with jejunal loops to right Malrotation with obstructing Duodenal bands

24. Proximal dilated stomach Crockscrew appearance of duodenum Malrotation with volvulus in a neonate

25. Normal position of duodenal bulb and c loop of duodenum Abnormal position of DJ flexure Malrotation with out volvulus in neonate