INTESTINAL MALROTATION OF ADULTS

Introduction

Intestinal malrotation is a congenital disease, which often presents within the first month of life. However, because of non-spesific presentation, sometimes this disease may not be recognized during childhood. Therefore, it may be seen in adults. Malrotation results not only in the malposition of the bowel but also in the malfixation of the mesentery. The normally broad mesenteric attachment is shortened to a narrow pedicle that predisposes the patient to the complication of midgut volvulus. Peritoneal fibrous bands (Ladd bands) are complication of malrotation, which may lead to interal hernia.

Case Report

48-year-old woman with acute abdominal pain was admitted to our hospital. Her history was significant for similar prior episodes without diagnosis. She was investigated several times for this pain, including five endoscopic examinations of upper gastrointestinal system. CT examination revealed characteristic whirllike appearance of bowel and mesentery wrapping around superior mesenteric artery (Figure-1, 2, 3). CT examination also showed malposition of the right colon and cecum. Cecum was located in epigastric region, and right colon was in left upper quadrant (Figure-4). Malrotation of midgut was made with these CT findings. The patient was operated and the operation confirmed the diagnosis. Abundant Ladd bands was also found in opeariton.

References

1) Perry J. Pickhardt and Sanjeev Bhalla (2002). Intestinal Malrotation in Adolescents and Adults: Spectrum of Clinical and Imaging Features. AJR, 179, Dec: 1429-1435.
2) Bozlar U, et al (2008). CT angiographic demonstration of a mesenteric vessel "whirlpool" in intestinal malrotation and midgut volvulus: a case report. Korean J Radiol. Sep-Oct; 9(5): 466-9.
3) Amaral L, et al (2009). Intestinal malrotation in the elderly. V. Am Surg. Jul; 75(7): 631-3.









Figure-1: Axial contrast-enhanced CT scans show characteristic clockwise twisting of bowel, mesentery, and superior mesenteric vein (arrows) around axis of superior mesenteric artery.
Figure-2: 3D color reconstruction of multislice CT of portal venous system clearly depicts the twisting (whirllike appearance) of superior mesenteric vein as well as the tortuose and enlarged branches (arrowheads). Portal vein (arrow)
Figure-3: Thick-slab average (mean) MPR reconstruction of abdomen in coronal plane revealed that right lower quadrant is filled with small intestine (arrows), beside, mobile cecum is located in a midline location close to stomach (arrowheads).
Figure-4: Axial MIP image of CT show characteristic clockwise twisting of mesentery, and superior mesenteric vein (arrow) around axis of superior mesenteric artery. (arrowhead).