K. L. Weaver1, A. S. Poola1, K. W. Gonzalez1, S. W. Sharp1, S. D. St. Peter1 1Children’s Mercy Hospital- University Of Missouri Kansas City,Pediatric General Surgery,Kansas City, MO, USA
Introduction:
Intestinal malrotation is often diagnosed in infancy. The true incidence of malrotation outside of this age is difficult to estimate because the majority either have an atypical presentation or are asymptomatic, being recognized only intraoperatively during other procedures. We sought to first determine the incidence, patterns of presenting symptoms, and what led to a final diagnosis of malrotation in patients over the age of one. We also analyzed anatomic intraoperative findings and its correlation with resolution of symptoms.
Methods:
A retrospective review was conducted in patients older than one year of age who were treated for malrotation at a single pediatric tertiary care center between January 2000 and January 2015 by the pediatric general surgery service. Data analyzed included age at presentation, presenting symptoms, radiographic imaging performed, surgical intervention, intraoperative findings and postoperative follow-up. Patients predisposed to malrotation (situs inversus, gastroschisis, omphalocele and congenital diaphragmatic hernia) were excluded.
Results:
A total of 246 patients were diagnosed with malrotation, of which 77 patients (31%) were found to be older than one year of age. Out of this population, 25% were found incidentally during investigations for other disease processes. The most common presenting symptoms were vomiting (68%), abdominal pain (57%), gastroesophageal reflux (18%), bilious vomiting (17%), constipation (17%) and failure to thrive (14%). 56% of patients had similar episodes of these symptoms in the past and 19% had chronic abdominal pain. The method leading to diagnosis included UGI (61%), CT (26%), intra-operative finding (6.5%) and other (6.5%) which included barium enema, esophagram, ultrasound, and CT angiogram. Sixty patients had an UGI during their workup, of which 83% were diagnostic for malrotation, 13% were ‘suspicious for’ malrotation and the remainder was non diagnostic. Out of these UGI’s obtained, 27 commented on the position of the ligament of treitz, 11 were reported as a low lying ligament or low duodenojujunal junction. Out of these 11 patients 10 were confirmed to have malrotation, with the 11th not receiving surgical exploration. Out of those patients radiologically diagnosed, 75 had surgical intervention with 97% confirmed to have malrotation. Sixty percent were found to have a malrotated intestinal orientation, 33% with nonrotated, and 1% with reverse rotated orientation. Twenty two percent were found to be obstructed with 12% having a volvulus. Of the 68 patients with postoperative follow up, 59% reported alleviation of symptoms, 15% remained asymptomatic, and 26% had persistence of preoperative symptoms.
Conclusion:
Malrotation should be on the differential list despite age given the highly variable clinical presentation. An UGI should be conducted first for a prompt diagnosis and surgical correction should be undertaken despite atypical presenting symptoms.