Reversed rotation of the midgut in adults – a case report

Abstract

A 25-year-old man presented via accident and emergency with pain in the left upper quadrant for 4 days. He had constipation for 3 days which progressed to absolute constipation. This was associated with increasing abdominal distension and vomiting of at least 10-15 times a day. He was known to have Gilbert's syndrome, depression and hay fever and had had no previous abdominal surgery. He was a smoker and used to drink alcohol moderately.On examination, he was apyrexial and haemodynamically stable. His abdomen was distended but non-tender, with increased bowel sounds. No hernias and digital rectal examination revealed an empty rectum with no other abnormalities. Full blood count revealed leucocytosis of WCC 14.2 × 10 9 cells/l. Plain abdominal X-ray showed dilated loops of small bowel which were pushed to the right side of the abdomen (Fig. 1). Chest X-ray revealed no abnormalities.He was treated conservatively overnight and re-assessed in the morning when a Gastrograffin follow through was obtained. This showed contrast in the stomach and the duodenum. The pyloric region of the stomach was displaced upward by a significantly enlarged, distended segment of large bowel (Fig. 2). The appearances were likely to represent a caecal volvulus. The rest of the contrast was vomited back. The decision was made to undertake an urgent exploratory laparotomy.Findings at laparotomy were of a caecal volvulus with ischaemia and serosal tears. Reversed rotation of midgut loop, through 90º in a clockwise direction. The transverse colon was seen to cross behind the superior mesenteric vessels (SMVs); the duodenum crosses in front of them; otherwise the disposition of the viscera appeared to be normal. The root of the mesentery of the small intestine (pre-arterial) has Intestinal obstruction is a common surgical emergency. It is often due to adhesions; however, when the patient is young and has a virgin abdomen, we have to consider uncommon causes. We present a rare case of reversed rotation of the midgut as a cause for intestinal obstruction. ON-LINE CASE REPORT

Novel variant of reversed midgut rotation – retro-arterial proximal jejunum and transverse colon: a case report and review of the literature

“…Other complications observed in reversed rotation anomalies are obstruction of the transverse colon by the SMA in the retro-arterial tunnel [ 17 – 21 ], volvulus (especially ileocecal) [ 15 – 19 ], and duodenojejunal obstruction. The latter may occur due to paraduodenal herniation or fibrous peritoneal bands [ 15 , 16 , 19 , 20 , 22 , 23 ]. These complications require rapid diagnosis and efficient surgical management.…”

Reverse intestinal rotation: a rare case of volvulus around a vitelline duct remnant

“…Second, the ascending colon can become obstructed from pressure created by the narrow tunnel posterior to the superior mesenteric vessels through which it passes. Finally, a duodenal obstruction, usually at the DJ flexure can develop secondary to mesenteric bands arising from the colon that extend over the duodenum to the retroperitoneum (Ladd's bands) 1 2. To the best of our knowledge, this is the first published case in the literature of RIR with intestinal volvulus around a Meckel's diverticulum attached to a remnant vitelline duct.…”

“…Midgut rotation anomalies are responsible for less than 1% of presentations of gastrointestinal obstruction in adults. Of these RIR was reported in 2–7% of cases, with a twofold female predominance 1 2. To the best of our knowledge, this is the first case report describing RIR with intestinal volvulus around the Meckel's diverticulum attached to the vitelline duct remnant.…”

“…Midgut rotational anomalies rarely present in adults, and are responsible for less than 1% of presentations of gastrointestinal obstruction in adulthood 1. Of these RIR is the rarest form of midgut rotation anomaly and is seen in only 2–7% of cases, with a twofold female predominance 1 2…”

“…The most common presentation is that of a gastrointestinal obstruction and several mechanisms have been implicated. First, the right colon or the entire midgut can undergo a volvulus 2. Second, the ascending colon can become obstructed from pressure created by the narrow tunnel posterior to the superior mesenteric vessels through which it passes.…”