2022, Number 1
Intestinal malrotation in a 50-year-old adult. Case report
Full text
10.35366/109319
Language: English/Spanish [Versi?n en espa?ol]
References: 10
Page: 44-49
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ABSTRACT
Introduction: intestinal malrotation is a congenital disorder associated with a lack of rotation of the midgut, often related to other congenital anomalies. It affects 1% of the population and is diagnosed in 90% of the cases before the age of one year. In adults the diagnosis is difficult, the symptoms are vague and unspecific, in many occasions the high intestinal occlusion is the only manifestation. Clinical case: 50-year-old male, with a history of early satiety, presents with abdominal distention with peritoneal irritation, abdominal radiography in standing and decubitus with hydroaereal levels, image in pile of coins, interasa edema and intestinal dilatation, proceed to exploratory laparotomy, finding, intestinal malrotation type IIIB, Ladd procedure is performed, observing; ascending colon and ileum in spiral, with impossibility for adequate fixation, with high risk of torsion and subsequent necrosis, it is decided right hemicolectomy with ileotransverse laterolateral anastomosis. Conclusions: Ladd's procedure is the surgical management of choice, however; in the presence of associated congenital alterations, each case will have to be individualized in order to minimize the risk of complications.INTRODUCTION
Intestinal malrotation is an anatomical defect caused by abnormalities in the rotation of the intestine in one of the three stages of embryonic development.
Stage I, rotation is given at 90o within the physiological umbilical hernia.
Stage II, a rotation of 180o occurs during the return to the abdominal cavity, completing the rotation of 270o.
In stage III, the cecum descends from the subhepatic level to the final position in the right iliac fossa; these changes originate between the fifth and twelfth week of gestation.
It is considered that midgut rotation anomalies (Table 1) present an incidence of one in 6,000 live newborns, and it is more frequent in males than in females; it is essential to know that intestinal malrotation is related to other anomalies, such as intestinal atresia 5-26%, Meckel's diverticulum 1-4%, hernia 7%, and trisomy 21 3-10%.1,2
It affects 1% of the population and is usually detected in 90% of cases before the age of one year.4 The clinical manifestations of intestinal malrotation are characterized by biliary vomiting and abdominal distension; as age advances, symptoms become vaguer but may include chronic abdominal pain, weight loss, failure to thrive, and other nonspecific complaints. Adult intestinal malrotation is often asymptomatic and is diagnosed incidentally during a radiological examination for another cause. However, it is common for these patients to report chronic symptoms with a history of episodes of acute pain and cyclic vomiting for years. Many are even labeled as psychological disorders, so diagnosis in adulthood can become complicated. A high percentage of these adults have clinical evidence of malnutrition due to intermittent intestinal occlusions, which alter the venous and lymphatic drainage of the intestine and produce malabsorption.5
High bowel occlusion may be the only clinical manifestation in the adult admitted to the emergency department due to extrinsic compression of Ladd's bands.
PRESENTATION OF THE CASE
The patient is a 50-year-old male, native and resident of Tepotzotlán, State of Mexico, Mexico, with a history of early satiety, when eating food since childhood and without any other added symptomatology.
His condition began 15 days prior to his hospital admission when he presented pain with a visual analog scale score of 4/10, of periumbilical location, gradual, and colicky type, with irradiation to the entire abdomen, of intermittent duration and frequency, aggravated with food intake, attenuated with rest, and accompanied by discrete abdominal distention. The patient's condition worsened two days prior to admission due to constant generalized pain and significant abdominal distention, with the impossibility of passing gas and evacuating; he came to the hospital for management and treatment. On physical examination, his vital signs were within normal parameters; he was conscious, calm, and oriented in his three neurological spheres, with good skin coloration and mucous membranes, painful facies, and forced attitude. He had an average general constitution, good hydration status, a normal skull without exostoses or sinkholes, cylindrical central neck without adenomegaly, cardiopulmonary without compromise, globose abdomen at the expense of abdominal distension, peristalsis of struggle, tympanic to percussion, with hyperesthesia and hyperalgesia throughout the abdomen, and with generalized involuntary muscle resistance. The rectal examination revealed an empty rectal ampulla.
Laboratory findings are shown in Tables 2, 3 and 4. Plain abdominal radiography in the standing position showed the presence of slight bowel distention, inter loop edema with a coin stack image, and hydro-aerial levels without air in the colon (Figure 1). Simple abdominal radiography in the supine position showed a coin stacking and a duodenal bubble image (Figure 2).
TREATMENT
Due to the poor response to conservative medical management for 24 hours, with the placement of a nasogastric tube and given the impossibility of having a complementary study such as a CT scan of the abdomen, it was decided to go to the operating room to perform an exploratory laparotomy. The preoperative diagnosis was high intestinal occlusion. On surgery, there were findings of intestinal occlusion by extrinsic duodenal compression and incomplete intestinal rotation, with the duodenum located to the right of the midline, Ladd peritoneal bands (Figure 3), significant duodenal dilatation (Figure 4), and an incomplete fixation of the hepatic angle of the colon in abnormal position. The presence of partial stenosis of jejunum at 15, 25, and 35 cm from the duodenum, two varicose veins of 1.5 cm in diameter, which run along the mesenteric border of the jejunum for approximately 150 cm (Figure 5), the jejunum with atrophy in its first 100 cm, and the hepatic angle of the colon located to the right of the midline were identified.
However, despite the lysis of adhesions, the cecum remains in a spiral form without the possibility of fixing it adequately, so a right hemicolectomy with manual anterolateral intertransverse anastomosis was performed. First, the ends of the transverse colon and ileum were closed in two planes: the first with polyglactin 2-0 simple suture, and the second plane was closed with separate Lembert stitches with 2-0 silk. Next, the anastomosis was performed in two planes, the first with polyglactin 2-0 single suture stitches on the posterior aspect of the anastomosis and a Connell Mayo stitch on the anterior aspect; and the second plane was closed with separate invaginating Lembert stitches with 2-0 silk.
During his hospitalization, the patient had a satisfactory clinical evolution; he restarted the oral route on the fifth day, and was managed with a double antibiotic regimen of ceftriaxone and metronidazole for seven days; at the end of the treatment, he was discharged to continue his outpatient follow-up, with no complications to date.
DISCUSSION
The diagnosis of intestinal malrotation in adults is complex, mainly due to the absence of specific previous signs and symptoms and its low incidence in this age range.6 Therefore, most of the time, this pathology is identified during surgery since adults are generally admitted to the emergency department with data of acute intestinal occlusion and, on many occasions, without more specific or specialized studies in some hospital units, which makes immediate surgical intervention necessary to avoid complications.
In newborns, infants, and children up to two years of age, intestinal malrotation should be corrected at the time of diagnosis since it is a surgical emergency; however, in older children and adults, this need is questionable because knowing that one suffers from this developmental anomaly allows immediate action to be taken in the event of any complication and, on the other hand, the frequency of symptoms at this age is lower.7
Consequently, many adults with this pathology, who have been asymptomatic during their lives, present some degree of malnutrition since the presence of chronic volvulus can cause intermittent and sporadic clinical manifestations, alter the venous and lymphatic drainage of the intestine, and produce malabsorption and hypoproteinemia.8
The Ladd procedure is the surgical treatment of choice described for the resolution of this anomaly; whereby the volvulus is reduced if present, the intestinal flanges are released, the mesenteric pedicle is widened to prevent midgut torsion, and the small and large bowel are fixed in their usual position, with the performance of a prophylactic appendectomy.9,10
However, in this reported case, and despite performing the maneuvers described above, the patient continued to have the ascending colon and terminal ileum in a spiral form without the possibility of an adequate and safe fixation; to avoid the possibility of intestinal torsion and subsequent necrosis, the decision was made to perform a right hemicolectomy with intertransverse anterolateral anastomosis, which resulted in a satisfactory evolution during his hospital stay and up to the present time.
CONCLUSIONS
Although the literature describes the surgical procedure to be performed in the presence of intestinal malrotation and the existing types of malrotation, the possibility of individual anatomical alterations is always latent. A surgical decision will have to be made according to the case presented, with the sole purpose of minimizing risks and favoring a good evolution for the patient's benefit.
REFERENCES
AFFILIATIONS
1 Department of General Surgery, Instituto de Salud del Estado de México, General Hospital of Tultitlán, General Surgeon.
2 Department of Pediatrics, Instituto de Salud del Estado de México, General Hospital of Tultitlán, Pediatrician.
Ethical considerations and responsibility: the authors declare that they followed the protocols of their work center on the publication of patient data, safeguarding their right to privacy through the confidentiality of their data.
Funding: no financial support was received for this work.
Disclosure: the authors declare no conflict of interest in carrying out the work.
CORRESPONDENCE
Ricardo García-Nieto. E-mail: dr.ricardogarcianieto@hotmail.comReceived: 01/19/2022. Accepted: 11/19/2022