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
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
Upper gastrointestinal
barium studies are not
obsolete
One can make a
FINAL DIAGNOSIS
on base of
sonography and
barium studies
alone
Compare with
normal
appearances of
upper GI barium
series to diagnose
MALROTATION
16. MIDGUT VOLVULUS
EMBRYOLOGY OF ROTATIONOF 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.
20. 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 3rd 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
21. Malrotation is usually daignosed in upto 75%
cases in newborns and upto 90% cases by 1st
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.
22. 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
23. 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 ofTreitz
24. DJ flexure with duodunal
bulb to right
Duodenal bulb with jejunal
loops to right