Intestinal Malrotation Clinical Presentation

Updated: Dec 08, 2016
  • Author: Denis D Bensard, MD, FACS, FAAP; Chief Editor: Carmen Cuffari, MD  more...
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Presentation

History

Intestinal malrotation can present as either an acute or chronic process. Additionally, various types of rotational defects are recognized. The history of present illness varies depending on these different factors.

Acute midgut volvulus

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  • Usually occurs during the first year of life
  • Sudden onset of bilious emesis
  • Diffuse abdominal pain out of proportion to physical examination

Chronic midgut volvulus

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  • Chronic midgut volvulus is due to intermittent or partial twisting that results in lymphatic and venous obstruction.
  • The most common symptoms are recurrent abdominal pain and malabsorption syndrome. [20]
  • Further history taking among older patients with acute midgut volvulus may reveal presence of missed diagnosis of chronic midgut volvulus.
  • Other clinical features include recurrent bouts of diarrhea alternating with constipation, intolerance of solid food, obstructive jaundice, and gastroesophageal reflux. [21]

Acute duodenal obstruction

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  • This anomaly is usually recognized in infants and is due to compression or kinking of the duodenum by peritoneal bands (Ladd bands).
  • Patients present with forceful vomiting, which may or may not be bile-stained, depending on the location of the obstruction with respect to the entrance of the common bile duct (ampulla of Vater).

Chronic duodenal obstruction

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  • The typical age at diagnosis ranges from infancy to preschool-age.
  • The most common symptom is vomiting, which is usually bilious.
  • Patients may also have failure to thrive and intermittent abdominal pain (frequently diagnosed as colic).

Internal herniation

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  • Internal herniation usually causes chronic symptoms.
  • Patients have recurrent abdominal pain, which may progress from intermittent to constant.
  • They experience vomiting as well as constipation at times.
  • They are often diagnosed with psychosocial problems.
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Physical

Physical examination findings may vary depending on the type of rotational defect as well as whether the symptoms are chronic or acute in onset.

Acute midgut volvulus

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  • This is usually associated with abdominal distention with diffuse tenderness and guarding on examination.
  • Prolonged volvulus leads to vascular compromise, which can cause intraluminal bleeding evidenced by melena and/or hematemesis.
  • Worsening intestinal ischemia can lead to signs of shock including poor perfusion, decreased urine output, hypotension, elevated lactate, and base deficit.
  • Other signs of intestinal ischemia include peritonitis and discoloration of the skin.

Chronic midgut volvulus

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  • Physical examination findings vary depending on whether the volvulus is present at the time of examination
  • If partial or complete volvulus is present at the time of examination, the patient may have signs and symptoms equivalent to those of acute midgut volvulus.
  • Patients usually have some degree of abdominal pain and distention.

Acute duodenal obstruction

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  • Abdominal distention and gastric waves may be present.
  • Passage of meconium or stool can be present.
  • These patients usually do not have signs of peritonitis or shock, unless volvulus is also present distal to the obstruction.

Chronic duodenal obstruction

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  • Physical examination findings may be completely normal at the time of presentation.
  • Abdominal distention and tenderness may be present.
  • Diagnosis is usually made by history and a high level of clinical suspicion; physical examination findings are very unreliable.

Internal herniation

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  • Physical examination findings can be unremarkable; diagnosis is made by a high index of clinical suspicion and radiologic studies.
  • Patients with left mesentericoparietal hernias may have findings related to venous obstruction, such as hematochezia, hemorrhoids, and dilated anterior abdominal veins.
  • If acute obstruction is present at the time of presentation, guarding and tenderness may be present and a globular mass may be palpated at the location of the hernia.
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Causes

See Pathophysiology.

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