Gastro-oesophageal reflux associated with duodenum inversum: two case reports and a review of the literature

Abstract

Gastro-oesophageal reflux disease (GORD) is a very common paediatric disorder and the majority of patients are treated successfully by primary care physicians. Two infants aged 2 months with GORD which did not respond to conventional medical management are reported; they were diagnosed with duodenum inversum. The first infant failed medical management and required Nissen's fundoplication to control his symptoms. The second infant improved on maximizing medical management without the need for a surgical procedure. These two cases highlight the need for further work-up in patients who do not respond to conventional GORD therapy and/or present with atypical clinical symptoms.

An Anatomic Red Herring Found in the Diagnosis of Functional Vomiting

“…A more recent case presented with partial intestinal obstruction and was managed with medical management involving NJ feeds and acid suppression [ 9 ]. Two pediatric case reports attributed duodenum inversum with clinically significant gastroesophageal reflux disease (GERD), which was managed with both pharmacologic and surgical intervention [ 10 ]. The initial presentation of our case differed from these in both the acute time course without demonstrated obstruction and lack of unintentional weight loss.…”

Duodenal Volvulus due to Duodenum Inversum

“…[1][2][3] Typically, patients are asymptomatic but can have a wide variety of presenting symptoms including epigastric pain, nausea, vomiting, obstruction, pancreatitis, cholecystitis, gastritis, reflux, and peptic ulcer disease. [1][2][3][4] In instances of obstruction, it is commonly due to adherent fibrotic bands similar to the Ladd's bands as seen in cases of malrotation. 4 In this case, we report a patient with undiagnosed duodenum inversum, presenting with acute abdominal pain and obstruction secondary to intermittent duodenal volvulus.…”

“…The etiology of duodenum inversum is unknown but may be due to a retained dorsal mesentery with a mobile duodenum. 1,2,4 Some consider it a variant form of duodenal rotation or fixation. 4 In the few cases that had undergone surgical exploration, the duodenal position of our patient was consistent with duodenum inversum with the cecum in normal anatomic location and a normal mesenteric width.…”

“…In 2012, 17 cases were reported since 1950, and it was noted that other associated conditions include incomplete to total intestinal malrotation, annular pancreas, pancreas divisum, and abnormal fixation of the right kidney. [1][2][3][4] There are approximately 73 reported cases in the literature. This condition is more common in men and adults.…”

“…However, in the case of duodenum inversum, the third portion travels posterior and lateral to the second portion superiorly to the level of the duodenal bulb and then crosses midline behind the duodenal bulb and ends at a normally positioned duodenal-jejunal junction at the ligament of Treitz. [1][2][3] Typically, patients are asymptomatic but can have a wide variety of presenting symptoms including epigastric pain, nausea, vomiting, obstruction, pancreatitis, cholecystitis, gastritis, reflux, and peptic ulcer disease. [1][2][3][4] In instances of obstruction, it is commonly due to adherent fibrotic bands similar to the Ladd's bands as seen in cases of malrotation.…”