Intestinal malrotation and volvulus beyond the neonatal period

ABSTRACT

Malrotation is a rare congenital malformation, commonly discovered in the first month of life. The diagnosis is however missed or delayed in a significant number of cases. This is especially so in children presenting beyond the neonatal period were they often present with a variety of atypical and frequently non-specific symptoms that may cause delay in diagnosis and treatment. This is a retrospective review of our experience with 11 infants and children with the diagnosis of mal-rotation presenting after the neonatal period treated at our hospital between 1990 and 2000. Sixteen infants and children were treated at our hospital during the study period. Three presented with intrauterine volvulus. Two presented within the first week of life with malrotation and volvulus. The remaining 11 were diagnosed late. In the majority, their symptoms dated back to birth. Six were malnourished and a large number were subjected to a variety of investigations including repeated upper and lower contrast studies and some received a number of unnecessary treatment modalities. All were operated on and underwent Ladd procedures and appendecectomies. In this group, there was no mortality but one of the patient required bowel resection. Malrotation represents a spectrum of anomalies that can present from as early as intrauterine to as late as adulthood. To obviate delay in diagnosis of malrotation with its catastrophic sequalae, physicians caring for these children should be aware of this and the possibility of malrotation should be suspected in any child who presents atypically with recurrent abdominal pain, vomiting especially if bile-stained, abdominal distension, and malnutrition. Once malrotation is diagnosed, the patient should be treated with a Ladd procedure. We advocate this even in asymptomatic children with incidentally diagnosed malrotation as it is difficult to predict the timing of midgut volvulus which is variable and unpredictable. We also advocate adding an appendecectomy as this will simplify their future management in case they present with abdominal emergency