Intestinal malrotation

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

obstruction with ischaemia

1st line – emergency surgery: open laparotomy and Ladd's procedure

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1st line –

emergency surgery: open laparotomy and Ladd's procedure

The acutely ill patient with midgut volvulus with vascular compromise presents with bilious vomiting, acute abdominal pain, tachycardia, tachypnoea, abdominal tenderness, acidosis, and potentially with signs of peritoneal catastrophe (e.g., guarding).

Emergency abdominal exploration, even without a radiographically confirmed diagnosis, is necessary.[10] Therefore, the surgeon should be contacted immediately when volvulus is clinically suspected in order to allow the surgeon opportunity to forgo further studies.

If the volvulus is associated with compromised flow of the superior mesenteric vessels, time is of the essence to salvage the involved intestine. Immediately on opening of the abdomen, the bowel is de-torsed by turning it in an anticlockwise direction to 'turn back the hands of time'.[10] Warm packs are applied to allow a period of observation to see whether the bowel will be viable. The Ladd's procedure is then completed.

Plus – supportive care

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Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

Nasogastric tube, antibiotic coverage for gram-negative organisms, and intravenous fluid resuscitation should be performed en route to the theatre.[11] Note that resuscitation should not preclude urgent surgical intervention, as manual detorsion of the bowel is the only way to reverse an otherwise fatal course.

Ceftriaxone plus metronidazole is recommended as a suitable antibiotic regimen for low-risk adults and children.[32][33] Subsequent adjustments to the antibiotic regimen may be necessary depending on the patient's microbiological profile and sensitivity tests. Consult your local protocols for further guidance.

Post-operative care is supportive in nature. The post-operative course is dictated by bowel rest until bowel activity resumes.

In the case of temporary closure or abdominal coverage with planned re-exploration, the patient should be sent to the intensive care unit, as there may be profound fluid shifts and haemodynamic perturbations that can progress rapidly. The course may mandate earlier re-operation sooner if the patient is unstable.

Primary options

ceftriaxone: neonates: consult specialist for guidance on dose; children: 50-75 mg/kg intravenously as a single dose within 60 minutes prior to surgery, maximum 2 g/dose; adults: 2 g intravenously as a single dose within 60 minutes prior to surgery

and

metronidazole: neonates: consult specialist for guidance on dose; children: 15 mg/kg intravenously as a single dose within 60 minutes prior to surgery, maximum 500 mg/dose; adults: 500 mg intravenously as a single dose within 60 minutes prior to surgery

ACUTE

obstruction without ischaemia

1st line – urgent surgery: open laparotomy and Ladd's procedure

Back

1st line –

urgent surgery: open laparotomy and Ladd's procedure

The patient with midgut volvulus without vascular compromise presents with bilious vomiting, crampy abdominal pain in waves, non-tender abdomen, and no severe physiological perturbation. There is typically time for rapid radiological confirmation.

Contrast may get through the torsion to give the corkscrew appearance, but this finding does not change the state of surgical urgency. Immediately on radiographic confirmation the surgeon should be called if not already involved in the care.

Immediately on opening of the abdomen, the bowel is de-torsed by turning it in an anti-clockwise direction. If there is any concern about bowel viability, warm packs are applied to allow a period of observation to see whether the bowel will be viable. The Ladd's procedure is then completed.

Plus – supportive care

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

Nasogastric tube and intravenous fluid resuscitation should be performed en route to the theatre but do not preclude an operation, as manual detorsion of the bowel is the only reversal of obstruction.

Antibiotics may be used prophylactically in patients with selected risk factors for surgical-site wound infection; gram-positive coverage should be used. Ceftriaxone plus metronidazole is recommended as a suitable antibiotic regimen for low-risk adults and children.[32][33] Subsequent adjustments to the antibiotic regimen may be necessary depending on the patient's microbiological profile and sensitivity tests. Consult your local protocols for further guidance.

Post-operative care is supportive in nature and the post-operative course is dictated by bowel rest until bowel activity resumes.

Primary options

and

intermittent or partial volvulus or obstructing Ladd's bands

1st line – timely surgery: Ladd's procedure (open or laparoscopic)

Back

1st line –

timely surgery: Ladd's procedure (open or laparoscopic)

The work-up of these patients, who present with intermittent vomiting but no signs of acute illness, consists solely of an upper gastrointestinal contrast series. If there is no malrotation, intermittent volvulus or Ladd's bands are ruled out but the contrast should be followed downstream with delayed images to rule out distal obstructing pathology. Malrotation diagnosed with this history should be operated on at the next feasible opportunity (e.g., next operating day), as this is not an emergency.

Laparoscopy may have a role in approaching these patients.[31][34][35][36] The operation remains the same with assuring no torsion around the base of the mesentery, complete duodenal mobilisation, appendectomy, possible widening of the mesentery, and placement of the small intestine on the right side of the abdomen with the colon on the left.

Feeding resumes with resumption of bowel activity (which is immediate after the laparoscopic approach).

Plus – supportive care

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

No nasogastric tube is necessary before or after the operation if obstruction is not present.

Intravenous fluids before the operation are needed for maintenance only during the pre-operative period of nothing by mouth.

Primary options

and

questionable malrotation or asymptomatic finding

1st line – elective surgery: Ladd's procedure (open or laparoscopic)

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1st line –

elective surgery: Ladd's procedure (open or laparoscopic)

These patients may be asymptomatic or have intestinal malrotation discovered as an incidental finding in investigating for reflux (fussiness, arching, apnoeic events, reactive airways, pneumonia).

If the contrast study confirms malrotation a Ladd's procedure can be scheduled electively, either open or laparoscopic. However, the diagnosis may not be clear in this population.

The duodenum may sweep normally, not be far enough to the left side, or lie low on the contrast study. The retro-peritoneal attachments may be normal (eliminating the risk of volvulus), but malrotation/non-rotation may be severe where the proximal bowel is lying to the left by circumstance.

Therefore, any radiographic findings suggesting malrotation as a possibility deserve exploration, which is preferably done laparoscopically in this scenario.[30] If malrotation is clearly present, the Ladd's procedure can be completed laparoscopically or converted to open depending on surgeon preference.

Plus – supportive care

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

Nasogastric tube is necessary after the operation. Intravenous fluids before the operation are needed for maintenance only during the pre-operative period of nothing by mouth.

Antibiotics may be used prophylactically in patients with selected risk factors for surgical-site wound infection; gram-positive/negative coverage should be used. Ceftriaxone plus metronidazole is recommended as a suitable antibiotic regimen for low-risk adults and children.[32][33] Subsequent adjustments to the antibiotic regimen may be necessary depending on the patient's microbiological profile and sensitivity tests. Consult your local protocols for further guidance.

Primary options

and

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Intestinal malrotation

Treatment algorithm

obstruction with ischaemia

emergency surgery: open laparotomy and Ladd's procedure

supportive care

Primary options

obstruction without ischaemia

urgent surgery: open laparotomy and Ladd's procedure

supportive care

Primary options

intermittent or partial volvulus or obstructing Ladd's bands

timely surgery: Ladd's procedure (open or laparoscopic)

supportive care

Primary options

questionable malrotation or asymptomatic finding

elective surgery: Ladd's procedure (open or laparoscopic)

supportive care

Primary options