Intestinal malrotation complicated with gastric cancer: A case report

BACKGROUND Intestinal malrotation is a congenital defect of embryonic development caused by various teratogenic factors.In this condition,the intestinal tube,along with the superior mesenteric artery serving as the axis for the counterclockwise movement,is incomplete or abnormally rotated due to incomplete attachment of the mesentery and abnormal intestinal tube position.Such a case is usually asymp-tomatic and thus difficult to detect.Therefore,similar variant malformations are only found during an operation required for other abdominal diseases.CASE SUMMARY An elderly male patient was admitted to the hospital due to gastric cancer.An abdominal computed tomography(CT)scan with contrast revealed that the ascending and descending colon were parallel on the right side of the abdominal cavity,while the sigmoid colon extended into the right iliac fossa,allowing the diagnosis of congenital midgut malrotation.Following thorough preoperative preparation,the patient underwent laparoscopic radical gastrectomy to treat his gastric cancer.Intraoperatively,an exploration of the abdominal cavity uncovered the absence of the transverse colon.The distal colon at the hepatic flexure,along with the ascending colon,extended into the right iliac fossa,where it continued as the sigmoid colon.As planned,the laparoscopic radical gastrectomy was perform-ed,and the patient was discharged from the hospital 7 d after the surgery.CONCLUSION Asymptomatic intestinal malrotation is best detected by CT,requiring no treatment but possibly interfering with the treatment of other diseases.

Packed with pills-obstructing duodenal web in the setting of intestinal malrotation:A case report

BACKGROUND The incidence of intestinal malrotation in adults has been reported to only be about 0.2%.Duodenal web as a cause of intestinal obstruction is rare,with an incidence of about 1:20000-1:40000.Furthermore,when described,these conditions are usually seen in early life and very infrequently in adulthood.CASE SUMMARY We report a case of a middle-aged woman with intestinal malrotation who presented with a three-month history of right-sided abdominal pain,early satiety,and a 22-pound weight loss.Patient underwent an esophagogastroduodenoscopy,which demonstrated numerous retained pills in a deformed first portion of the duodenum,concerning for a partial gastric outlet obstruction.An upper gastrointestinal series showed marked distention of the proximal duodenum with retained debris and the presence of a windsock sign,increasing the suspicion of a duodenal web.The patient subsequently underwent surgical intervention where a duodenal web with two lumens was noted and resected,opening the duodenum.There were over 150 pill capsules that were removed.The patient is doing well after this intervention.CONCLUSION Both intestinal malrotation and duodenal webs are infrequently encountered in the adult population.These pathologies can also present with nonspecific abdominal symptoms such as chronic abdominal pain and nausea.Hence,providers might not consider these pathologies in the differential for patients who present with vague symptoms which can lead to delay in management and increased mortality and morbidity.

Adult duodenal intussusception associated with congenital malrotation

Enteroenteric intussusception is a condition in which full-thickness bowel wall becomes telescoped into the lumen of distal bowel. In adults, there is usually an abnormality acting as a lead point, usually a Meckels＇ diverticulum, a hamartoma or a tumour. Duodeno- duodenal intussusception is exceptionally rare because the retroperitoneal situation fixes the duodenal wall. The aim of this report is to describe the first published case of this condition. A patient with duodeno-duodenal intussusception secondary to an ampullary lesion is reported. A 66 year-old lady presented with intermittent abdominal pain, weight loss and anaemia. Ultrasound scanning showed dilated bile and pancreatic ducts. CT scanning revealed intussusception involving the full-thickness duodenal wall. The lead point was an ampullary villous adenoma. Congenital partial （type r[） malrotation was found at operation and this abnormality permitted excessive mobility of the duodenal wall such that intussusception was possible. This condition can be diagnosed using enhanced CT. Intussusception can be complicated by bowel obstruction, ischaemia or bleeding, and therefore the underlying cause should be treated as soon as possible.

Recurrent intestinal volvulus in midgut malrotation causing acute bowel obstruction: A case report

Intestinal malrotation occurs when there is a disruption in the normal embryological development of the bowel. The majority of patients present with clinical features in childhood, though rarely a first presentation can take place in adulthood. Recurrent bowel obstruction in patients with previous abdominal operation for midgut malrotation is mostly due to adhesions but very few reported cases have been due to recurrent volvulus. We present the case of a 22-year-old gentleman who had laparotomy in childhood for small bowel volvulus and then presented with acute bowel obstruction. Preoperative computerised tomography scan showed small bowel obstruction and features in keeping with midgut malrotation. Emergency laparotomy findings confirmed midgut malrotation with absent appendix, abnormal location of caecum, ascending colon and small bowel. In addition, there were small bowel volvulus and a segment of terminal ileal stricture. Limited right hemicolectomy was performed with excellent postoperative recovery. This case is presented to illustrate a rare occurrence and raise an awareness of the possibility of dreadful recurrent volvulus even several years following an initial Ladd's procedure for midgut malrotation. Therefore, one will need to exercise a high index of suspicion and this becomes very crucial in order to ensure prompt surgical intervention and thereby preventing an attendant bowel ischaemia with its associated high fatality.

Malrotation: Current strategies navigating the radiologic diagnosis of a surgical emergency

The most accurate and practical imaging algorithm for the diagnosis of intestinal malrotation can be a complex and sometimes controversial topic.Since 1900,sig-nificant advances have been made in the radiographic assessment of infants and children suspected to have anomalies of intestinal rotation.We describe the cur-rent methods of abdominal imaging of malrotation along with their pros and cons.When associated with volvulus,malrotation is a true surgical emergency re-quiring rapid diagnosis and treatment.We emphasize the importance of close cooperation and communica-tion between radiology and surgery to perform an effective and efficient diagnostic evaluation allowing prompt surgical decision making.

Situs inversus abdominus and malrotation in an adult with Ladd's band formation leading to intestinal ischaemia

Situs inversus abdominus with rotational anomaly of the intestines is an extremely rare condition. Although intestinal malrotation has been recognized as a cause of obstruction in infants and children and may be complicated by intestinal ischaemia, it is very rare in adults. When it occurs in the adult patient, it may present acutely as bowel obstruction or intestinal ischaemia or chronically as vague intermittent abdominal pain. Herein, we present an acute presentation of a case of situs inversus abdominus and intestinal malrotation with Ladd＇s band leading to infarction of the intestine in a 32 year old woman.

Malrotation causing duodenal chronic obstruction in an adult

Congenital duodenal obstruction is rare in adulthood. An unusual presentation of this condition has led to difficult preoperative diagnosis.We present a case of proximal jejunal obstruction by a congenital band in an adult and review the literature.

Congenital intestinal malrotation with gastric wall defects causing extensive gut necrosis and short gut syndrome:A case report

BACKGROUND Congenital intestinal malrotation(CIM)is a common malformation in neonates.Early diagnosis and surgical intervention can improve the prognosis.CIM combined with congenital gastric wall defect is a potentially fatal condition.We present a severe case of CIM with gastric wall defect causing extensive gut necrosis and short gut syndrome.After three operations,the neonate survived and subsequently showed normal growth and development during infancy.CASE SUMMARY A male neonate(age:4 d)was hospitalized due to bloody stools and vomiting for 2 d,and abdominal distention for 1 d.Emergent exploratory laparotomy revealed black purplish discoloration of the bowel loops.Bowel alignment was abnormal with congestion and dilatation of the entire intestine,and clockwise mesentery volvulus(720°).The posterior wall of the gastric body near the greater curvature showed a defect in the muscularis layer(approximately 5.5 cm),and a circular perforation(approximately 3 cm diameter)at the center of this defect.Ladd’s procedure was performed and gastric wall defect was repaired.Third operation performed 53 d after birth revealed extensive adherence of small intestine and peritoneum,and adhesion angulated between many small intestinal loops.We performed intestinal adhesiolysis,resection of necrotic intestine,and small bowel anastomosis.CONCLUSION This case highlights that prolonged medical treatment may help improve intestinal salvage after surgical removal of necrotic intestines,and improve patient prognosis.

Gastric Malrotation Relieved by Pleural Effusion Drainage

Mr M., 55-year-old, with metastatic adenocarcinoma of lung (stage IV) was admitted to the hospital after an earlier visit to oncology, where he presented with abdominal pain and distention suspected of having ascites for the first time. After performing abdominal CT and gastric passage film, it was hypothesized that clinical manifestation was related to gastric malrotation. The latter was forced by the huge left pleural effusion. Draining the pleural effusion may be complicated by a trapped lung, an adverse effect where the lung does not expand post drainage. After considering the palliative therapeutic options the effusion was drained, the stomach recoiled to its anatomical position, gastric malrotation was relieved, and the patient resumed oral nutrition. Though gastric malrotation due to a huge, malignant left pleural effusion is rare, it should be considered as more patients are being treated for lung cancer.

Left-sided appendicitis:Review of 95 published cases and a case report

AIM:To give an overview of the literature on left-sided acute appendicitis (LSAA) associated with situs inversus totalis (SIT) and midgut malrotation (MM).METHODS:We present a new case of LSAA with SIT and a literature review of studies published in the English language on LSAA,accessed via PubMed and Google Scholar databases.RESULTS:Ninety-five published cases of LSAA were evaluated and a 25-year-old female,who presented to our clinic with left lower abdominal pain caused by LSAA,is reported.In the reviewed literature,fiftyseven patients were male and 38 were female with an age range of 8 to 82 years and a median age of 29.1 ± 15.9 years.Sixty-six patients had SIT,23 had MM,three had cecal malrotation,and two had a previously unnoted congenital abnormality.Fifty-nine patients had presentedto the hospital with left lower,14 with right lower and seven with bilateral lower quadrant pain,and seven subjects complained of left upper quadrant pain.The diagnosis was established preoperatively in 49 patients,intraoperatively in 19,and during the postoperative period in five;14 patients were aware of having this anomaly.The data of eight patients were not unavailable.Eleven patients underwent laparoscopic appendectomy,which was combined with cholecystectomy in two cases.Histopathological examination of the appendix specimens revealed adenocarcinoma in only two of 95 patients.CONCLUSION:The diagnosis of left lower quadrant pain is based on well-established clinical symptoms,physical examination and physician's experience.

Anterior knee pain after a total knee arthroplasty: What can cause this pain?

Total Knee Arthroplasty has been shown to be a successful procedure for treating patients with osteoarthritis,and yet approximately 5%-10%of patients experience residual pain,especially in the anterior part of the knee.Many theories have been proposed to explain the etiology of this anterior knee pain(AKP)but,despite improvements having been made,AKP remains a problem.AKP can be described as retropatellar or peripatellar pain,which limits patients in their everyday lives.Patients suffering from AKP experience difficulty in standing up from a chair,walking up and down stairs and riding a bicycle.The question asked was:"How can a‘perfectly’placed total knee arthroplasty(TKA)still be painful:what can cause this pain?".To prevent AKP after TKA it is important to first identify the different anatomical structures that can cause this pain.Greater attention to and understanding of AKP should lead to significant pain relief and greater overall patient satisfaction after TKA.This article is a review of what pain is,how nerve signalling works and what is thought to cause Anterior Knee Pain after a Total Knee Arthroplasty.

Intestinal obstruction in pregnancy with reverse rotation of the midgut:A case report

BACKGROUND Reverse rotation of the midgut is a rare type of intestinal malrotation.Volvulus of the right colon or entire midgut,stenosis of the transverse colon and obstruction of the duodenojejunal junction are common complications of reverse rotation.In this study,we report the first case of intestinal obstruction associated with reverse rotation in pregnancy.CASE SUMMARY A 31-year-old woman at 362+wk gestation presented to the emergency department with progressive abdominal cramping,nausea and bilious vomiting.Abdominal ultrasound scanning showed dilatation of the bowel.Computed tomography scanning revealed features of reverse rotation of the midgut with intestinal volvulus.After consultation with the obstetrician,the pregnancy was terminated and exploratory abdominal surgery was performed.Intra-operatively,it was found that the mesentery of the colon and small intestine was insufficiently attached.The right colon and the small intestinal mesentery was twisted,and intestinal necrosis was observed.The duodenum and duodenojejunal junction were curved in front of the transverse colon,and the transverse colon passed through the tunnel behind the mesenteric root.Intestinal reverse rotation with volvulus was confirmed.The necrotic intestine was resected and small intestine mesenteric reconstruction was performed.The patient recovered after surgery.After leaving the hospital,the patient and her daughter remained well during an 8-month follow-up period.CONCLUSION We report the diagnosis,treatment and etiology of a pregnant patient with intestinal obstruction due to reverse rotation of the midgut.For similar cases,appropriate diagnosis and treatment should be carried out according to the condition of the fetus and pregnant woman.

Abdominal separation in an adult male patient with acute abdominal pain

We report a male patient with prolonged post-prandial abdominal distension and a sudden onset of epigastric pain initially diagnosed as acute abdomen. The patient had no history of surgery. Physical examination revealed peritonitis and abdominal computed tomography scan showed upper abdominal mesentery intorsion. The patient then underwent surgical intervention. It was found that the descending mesocolon dorsal root was connected to the ascending colon and formed a membrane encapsulating the small intestine. The membrane also formed an orifice in the ileal pars caeca, from which a 30 cm herniated ileum formed a "C"-shaped loop which was strangulated by the orifice. An abdominal separation was diagnosed after surgery. We liberated the membranous peritoneum which incarcerated the intestinal canal from the root ofileocecal junction to Treitz ligament, and reduced the small intestinal malrotation. The patient had an uneventful recovery after opera-tion with his abdominal distention disappeared during the follow-up. Abdominal separation is a rare situation, which may be related with embryo development. Surgery is a choice of treatment for it.

Volvulus of the ascending colon in a non-rotated midgut:Plain film and MDCT findings

Colonic volvulus is a relatively uncommon cause of large bowel obstruction usually involving mobile,intraperitoneal,colonic segments.Congenital or acquired anatomic variation may be associated with an increased risk of colonic volvulus which can occasionally involve retro-peritoneal segments.We report a case of 54-year-old female who presented to our Institution to perform a plain abdominal film series for acute onset of cramping abdominal pain.Both the upright and supine films showed signs of acute colonic obstruction which was thought to be due to an internal hernia of the transverse colon into the lesser sac.The patient was therefore submitted to a multi-detector contrast-enhanced computed tomography(CT).CT findings were initially thought to be consistent with the presumed diagnosis of internal hernia but further evaluation and coronal reformatting clearly depicted the presence of a colonic volvulus possibly resulting from a retro-gastric colon.At surgery,a volvulus of the ascending colon was found and a right hemi-colectomy had to be performed.However,a non rotated midgut with a right-sided duodeno-jejunal flexure and a left sided colon was also found at laparotomy and over-looked in the pre-operative CT.Retrospective evaluation of CT images was therefore performed and a number of CT signs of intestinal malrotation could be identified.

Derotational osteotomy and internal fixation of a 180°malrotated humerus:A case report

BACKGROUND Humeral shaft fractures are relatively common in adults.Rotational malalignment is reported as one complication but severe rotational deformity of the humerus is extremely rare.To our knowledge,only three cases of symptomatic humeral malrotation have been reported.There are sparse literature reports of humeral reconstruction correction.CASE SUMMARY We present a case of extreme rotational deformity of the humerus(180°)after humeral shaft fracture.The patient complained of pain and difficulties with activities of daily living.In addition,she found the deformity cosmetically unacceptable.Therefore,she was searching for surgical correction.Neurolysis of the radial nerve followed by derotational osteotomy of the humerus and internal fixation were performed.Postoperatively,the patient demonstrated transient iatrogenic radial nerve palsy which recovered completely during postoperative follow-up.The Disabilities of the Arm,Shoulder,and Hand score improved from 55 preoperatively to 16 at the final 2-year follow-up.CONCLUSION Single-stage radial neurolysis,derotational osteotomy and stable fixation is a feasible option to improve anatomic and functional problems of severely malrotated humeral shaft fractures.

Symptomatic Pelvic Kidney in Women at Childbearing Potential: Diagnostic Difficulties and Management in Urology Department of N’Djamena in Chad

Introduction: We aim to report, from three observations, the diagnostic difficulties and complications, and ensure the management of pelvic kidney in women at childbearing age in the Urology Department of the National General Referral Hospital of N’Djamena. Pelvic kidney is due to an abnormality of the migration that can be associated or not with a malrotation. Its symptomatology is not specific, causing diagnostic difficulties and therapeutic errors. Observation: There were three observations of female patients aged respectively 26, 29 and 32 years who were taken care of for years in the gynecology department for pelvic inflammatory disease before being routed in urology. The diagnosis of pelvic kidney was retained on the basis of morphological examination (ultrasound, intravenous urography, CT urography). The patients have undergone nephrectomy;the postoperative aftermath was simple. Conclusion: Pelvic kidney is a rare disease. It is often discovered during autopsy. Symptoms are non-specific;nephrectomy is the treatment of choice in symptomatic cases.

Situs Inversus Totalis with Left-Sided Appendicitis: A Case Report

Introduction: Left-sided acute appendicitis (LSAA) develops in association with two types of congenital anomalies: situs inversus totalis (SIT) and midgut malrotation (MM). A Left sided appendicitis is an ambiguous and difficult diagnosis to make. Aim: To present a proven case of left-sided acute appendicitis (LSAA) associated with situs inversus totalis (SIT). Case Report: A case of Left appendicitis was evaluated in a 28-year-old Asian male, who presented to our hospital in Feb. 2016, with lower abdominal pain more on left side and suspected diverticulitis or acute appendicitis with unusual appendix location. The patient doesn’t recall any history of abdominal surgery or about situs inversus totalis, abdominal and pelvic ultrasound was done, left iliac fossa appendicitis was diagnosed, Erect chest X-ray including upper abdomen revealed dextrocardia and stomach air on right side (situs inversus totalis), the patient underwent diagnostic Laproscop and Endoscopic resection of the appendix, with no incidents, and then discharged without complications, follow visits went unremarkable. Conclusion: The diagnosis of left lower quadrant pain is based on well-established clinical symptoms, physical examination and physician’s experience.

Long-axis rotational volvulus in an ileal J-pouch anal anastomosis: A preventable rare complication

Puropose: This study was designed to report a very rare long-term complication of ileal-Jpouch anal anastomosis: An 180 degree longaxial rotational volvulus causing J pouch obstruction. Methods: An Ovid and Medline search using the following keywords was performed: J pouch ileoanal anastomosis, J-pouch ileoanal anastomosis complications, J-pouch volvulus, J-pouch complications, restorative proctocolectomy complications, and restorative proctocolectomy volvulus. One J-pouch ileoanal anastomosis 180° volvulus report was found [1]. Result: We describe a long-axis 180° rotational volvulus complication of a J-pouch ileoanal anastomosis. The J pouch was performed three years prior after the laparoscopic total proctocolectomy for chronic ulcerative colitis. Pouch excision and new ileoanal J-pouch surgery were then performed along with pexy using alloderm mesh placement with excellent outcomes. Conclusion: Long-axis 180° rotational volvulus is a rare complication of a J-pouch ileoanal anastomosis. Pouch dysfunction after a long-axis rotational volvulus is an uncommon cause of acute abdomen. Lack of adhesions and pouch size are risk factors for the pouch torsion. Prompt diagnosis and treatment are essential for the pouch salvage. Simple abdominal x-ray, barium enema and CT scan represent important tools for diagnosis. Salvage surgery should be performed even if detorsion and decompression of the affected bowel are achieved. Surgery has excellent outcomes if performed after the prompt diagnosis. Pouch pexy should be done to prevent recurrent volvulus.