Clinical case
Adult intestinal malrotation associated with intestinal volvulus
Malrotación intestinal en adulto asociada a vólvulo intestinal
Ernesto Hernando-Almudía,
, Rafael Cerdán-Pascuala, Cristina Vallejo-Bernada, Joaquín Martín-Cuarterob, María Sánchez-Rubioa, Carmen Casamayor-Francoa
Corresponding author
ernestohernando@gmail.com
Corresponding author at: Avenida de Madrid 191, 4B, 50017 Zaragoza, Spain. Tel.: +34 9765 32171/+34 6179 23385.
Corresponding author at: Avenida de Madrid 191, 4B, 50017 Zaragoza, Spain. Tel.: +34 9765 32171/+34 6179 23385.
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Tel.: +34 9765 32171/+34 6179 23385." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Malrotación intestinal en adulto asociada a vólvulo intestinal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 913 "Ancho" => 950 "Tamanyo" => 169163 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Anomalous position of the mesenteric vessels.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">The term Intestinal malrotation may be defined as: a congenital anomaly of the intestinal rotation and fixation during the development of the foetus. A great variety of anomalies exist and these may remain asymptomatic throughout life or be accompanied by acute abdomen, generally in the form of associated intestinal volvulus.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Changes in embryological intestinal development may occur in any of its phases and may be grouped in accordance with the corresponding development stage<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a>:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0015" class="elsevierStylePara elsevierViewall">Non-rotation: here the small intestine is located on the right of the abdomen. The distal ileum crosses the midline to the caecum, located on the midline.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0020" class="elsevierStylePara elsevierViewall">Incomplete rotation: the intestine occupies an intermediate position between non rotation and standard layout.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0025" class="elsevierStylePara elsevierViewall">Inverse rotation: the duodenum crosses in front of the superior mesenteric artery, and the colon goes behind it. The duodenum is therefore in front, the superior mesenteric artery is behind it and behind this is the transverse colon.</p></li></ul></p><p id="par0030" class="elsevierStylePara elsevierViewall">In general malposition of the intestine in itself does not lead to problems, but it is often associated with bad intestinal adherence which may predispose to intestinal volvulus.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Clinical case</span><p id="par0035" class="elsevierStylePara elsevierViewall">A patient aged 46 with no clinical history of note, presented at the emergency department with a three-day history of repeated vomiting and absence of bowel movements. The patient had previously presented at a hospital on 2 occasions, but without any organic causes. On this occasion symptoms included abdominal pain of epigastric origin, which was later diffuse. On examination the abdomen was found to be swollen and slightly painful, without peritoneal irritation.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Blood count was normal, biochemical studies revealed a slight increase in urea and creatine and a PCR of 2.4. A simple X-ray of the abdomen showed swelling of the small intestine loops, compatible with a partial bowel obstruction.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The patient was admitted to the service of digestive medicine and following exacerbation of pain during the next few hours, computed axial tomography (CAT) of the abdomen was requested. This showed swelling of the small intestine loops in the right abdomen, displacing the caecum to a posterior and central position (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). There was also abundant free fluid indicative of loop impairment and focused grouping of mesenteric vessels, suggestive of internal hernia or torsion (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The radiologist suggested a primary diagnosis of pericaecal internal hernia. Retrospectively an inversion of mesenteric vessels was observed (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">A surgical assessment was requested and on examination the patient presented with a very swollen, diffusely painful abdomen, low peristalsis and considerable compromise of the patient's general health status.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Emergency surgery was performed, with an exploratory laparotomy, which revealed the beginning of an irreversible intestinal ischaemia of 150<span class="elsevierStyleHsp" style=""></span>cm of ileum and a large herniated sac in the right abdomen, with the caecum in medial position and almost 1<span class="elsevierStyleHsp" style=""></span>l of intra-abdominal fluid.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The herniated sac which contained dilated jejunum was opened and resected and we confirmed the existence of an intestinal malrotation existing from the angle of Treitz to the left of the mesenteric vessels, in addition to an intestinal volvulus (<a class="elsevierStyleCrossRefs" href="#fig0020">Figs. 4 and 5</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Removal of the largest part of the mesenteric sac and resection of 150<span class="elsevierStyleHsp" style=""></span>cm of the compromised intestine was performed, remaining 300<span class="elsevierStyleHsp" style=""></span>cm above and 16<span class="elsevierStyleHsp" style=""></span>cm from the end of the ileum, with side-to-side manual isoperistaltic anastomosis.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The postoperative period passed without event and the patient was discharged 7 days after surgery.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">Intestinal malrotation is determined by an interruption or alteration of the embryological development of the midgut, in any of its phases, whereby it divides into 2 parts through the superior mesenteric artery axis. The proximal part, which later becomes the duodenal-jejunal loop, is located above and anterior to the superior mesenteric artery. The distal part is posterior and inferior to the artery and becomes the ileum, ascending colon and proximal transverse colon.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Prevalence in adults is estimated to be 0.2%,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> and it is mainly asymptomatic, and diagnosed as a casual finding during a radiological examination performed for other reasons. Diagnosis in adults is difficult due to low incidence and the CAT scan is the technique of choice.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">What is characteristic about the CAT scan is the medial position of the caecum and the lateral position of the small intestine loops, and inversion of mesenteric vessels. In our case, which was complicated by a volvulus, there was dilation of the small intestine loops, free fluid and grouping of mesenteric vessels, similar to agitated vessels.</p><p id="par0090" class="elsevierStylePara elsevierViewall">On other occasions we may refer to chronic symptoms with episodes of abdominal pain and vomiting, even evidence of malnutrition associated with malabsorption, due to intermittent chronic volvulus. The incidence of intestinal volvulus is high (33% of cases) regardless of age, and acute abdomen should therefore be treated as an emergency.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Defining the exact type of malrotation is of little clinical interest since they all predispose to volvulus, and the important point is to diagnose the existence of volvulus. Treatment is surgical, with devolvulation of the small intestine loops, releasing the membranes attached to them, separating the common meso colon and an appendectomy, given that the abnormal situation of the caecum inhibits a posterior diagnosis of appendicitis.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusions</span><p id="par0100" class="elsevierStylePara elsevierViewall">The clinical presentation of intestinal malrotation in an adult is asymptomatic in the majority of cases. Diagnosis is usually coincidental to radiological examination, usually from computed tomography performed for a different reason. It is infrequently associated with acute abdomen, where diagnosis occurs during laparotomy.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interests</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres986539" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Clinical case" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec954138" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres986540" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Caso clínico" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec954139" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical case" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-04-04" "fechaAceptado" => "2016-05-17" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec954138" "palabras" => array:3 [ 0 => "Intestinal malrotation" 1 => "Intestinal volvulus" 2 => "Intestinal obstruction" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec954139" "palabras" => array:3 [ 0 => "Malrotación intestinal" 1 => "Vólvulo intestinal" 2 => "Obstrucción intestinal" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Intestinal malrotation is a congenital anomaly of the intestinal rotation and fixation, and usually occurs in the neonatal age.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Description of a clinical case associated with acute occlusive symptoms.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Clinical case</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A case of intestinal malrotation is presented in a previously asymptomatic woman of 46 years old with an intestinal obstruction, with radiology and surgical findings showing an absence of intestinal rotation.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Intestinal malrotation in adults is often asymptomatic, and is diagnosed as a casual finding during a radiological examination performed for other reasons. Infrequently, it can be diagnosed in adults, associated with an acute abdomen.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Clinical case" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La malrotación intestinal es una anomalía congénita de la rotación y fijación intestinal, que se presenta generalmente en la edad neonatal.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Objetivo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Descripción de un caso clínico asociado a un cuadro oclusivo agudo.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Caso clínico</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Presentamos el caso de una mujer de 46 años, previamente asintomática, atendida por un cuadro de obstrucción intestinal, con el hallazgo radiológico y quirúrgico de una ausencia de rotación intestinal.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La malrotación intestinal en el adulto, frecuentemente es asintomática, y se diagnostica de una forma casual, en el curso de una exploración radiológica realizada por otra causa. De forma infrecuente puede diagnosticarse en adultos, asociado a un cuadro de abdomen agudo.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Caso clínico" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Hernando-Almudí E, Cerdán-Pascual R, Vallejo-Bernad C, Martín-Cuartero J, Sánchez-Rubio M, Casamayor-Franco M. Malrotación intestinal en adulto asociada a vólvulo intestinal. Cirugía y Cirujanos. 2017;85:424–427.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 690 "Ancho" => 950 "Tamanyo" => 85230 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Intravenous contrast enhanced computed tomography axial imaging of the abdomen. Dilation of small intestine loops and presence of ascitic fluid (asterisk). Abnormal position of caecum, located mid line (arrow).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 822 "Ancho" => 950 "Tamanyo" => 117304 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Coronal reconstruction of intravenous contrast enhanced computed tomography of abdomen. General dilation of small intestine loops and presence of ascitic fluid. Mesenteric vessels groups at volvulus axis level (circle), responsible for occlusion.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 853 "Ancho" => 950 "Tamanyo" => 93482 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Intravenous contrast enhanced computed tomography axial imaging of the abdomen. Inversion of the mesenteric vessels, with superior mesenteric artery (thin arrow) located to the right of the superior mesenteric vein (thick arrow).</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 679 "Ancho" => 950 "Tamanyo" => 139179 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Mesenteric sac open and protrusion of jejunum at the angle of Treitz.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 913 "Ancho" => 950 "Tamanyo" => 169163 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Anomalous position of the mesenteric vessels.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Aspectos embriológicos, clínicos y radiológicos de la malrotación intestinal" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "T. 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