Gut Malrotation, Nonrotation and Volvulus for USMLE
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- Опубліковано 30 вер 2024
- Gut Malrotation, Nonrotation, and Volvulus is arrest of the normal gut as it rotates around the super mesenteric artery. Embryology, Signs and Symptoms, Diagnosis and Treatment for students taking USMLE Step 2.
EMBRYOLOGY
Normal at 6 weeks the gut goes through the yolk sac and as time goes on it continues to enlarge and goes into the yolk sac even further. At 9 weeks there is rotation of the gut and the distal part of the gut rotates until it is anterior to the proximal part of the gut. Afterwards the gut returns to the fetus abdomin and there is another 180 degree rotation continues. Therefore there is a total of 270 degree of rotation around the Superior mesenteric artery. There are two types of malrotation. The first type of gut malrotation is gut nonrotation and gut malrotation.
In gut nonrotation the the colon is on the left side of the small bowel. In gut malrotation, rotation does occur for a little bit but becomes arrested when on the way and therefore there is no downward movement. Gut malrotation is associated with more clinical findings due to the mesentary. The mesenteric base is really small and normally it goes from the duodenojejunal flexure down to the cecum. However, in gut malrotation it is much easier for it to spin on itself and this is known as volvulus. There is also formation of Ladd Bands which goes over the dudoenum and causes obstruction of dodenum.
Sign and symptoms of gut malrotation is related to the narrow mesentery allowing volvulus to occur which can lead to ischemia and necrosis. Ladd bands will cause duodenal obstruction.
Presentation of gut malrotation starts in infancy with biluous vomiting. There is also abdominal pain and distention. If volvulus occurs there may be some associated bloody stool which is a poor sign because it suggests ischemia and necrosis of the gut. This may lead to sepsis and fluid third spacing and therefore you must maintain fluid levels. Volvulos ocurs in about 22% in children and 12% in adults. There are a few differential diagnosis. Age is the biggest factor. In the pre-term group there is necrotizing enterocolitis and this can differentiated by x-ray. In older infants there may be intussesception which is telescoping of the small intestine, which can be done through ultrasound bulls eye sign.
On X-ray there will be gas and double bubble sign due to dudodenal obstruction from Ladd bands blocking dudodenum. Barium swallow or Gi series which is highlight the walls of the very nicely. In Volvulus there will be a classical corkscrew appearance. Often times there will be a misplaced dudonum which can be highlighted as well. Another imaging modality you can use Barium Enema, which will highlight the colon. The cecum is present on the right side of the abdomen. In a patient with gut nonrotation the cecm is on the left side of the large bowel. An ultrasound can also be performed and will show abnormal placement of the duodenum, Superior mesenteric Artery and Superior Mesenteric Vein. In volvulus there will be a classic whirpool sign.A CT scan is not perferred in children and adolescent, but in adults it can show perforation. Same findings on CT scan that are normally seen on Ultrasound. If findings are still equivocal than a laparatomy may be performed.
TREATMENT is primarily a surgical procedure known as the Ladd Procedure. The bowel is not returned to the normal position. The mesenteric base is widened, the Ladd Bands are removed and appendix is removed Adverse effects of Ladd Procedure may be short bowel syndrome can no longer absorb enough nutrients required. It may also leads to adhesions which may lead to intestinal obstruction. Prognosis is good because 89% will resolve. Mortality rate is zero with normal infants, but a slightly higher risk of mortality if there are other features.
Is volvulus genetic? Four years ago, my youngest 10 year old son had this condition and wasn't diagnosed until after he went septic because all but about 2 cm of his small intestines died. Unfortunately, went into septic shock and was down for about 17minutes which caused much brain damage. He survived the surgery but the brain damage was too much for him to have a meaningful recovery. We decided that life on a ventilator would not be him so we decided to let him go. So, I now ask the genetics question to see the likelihood of either of my other kids passing this on to their kids. Thank you for your lesson. It was very helpful for me to understand what happened.
No sir, Volvulus is not always genetic. This video shows volvulus neonatorum which is a congenital malrotation of intestine during the development of gut in fetus (baby).
Volvulus may occur in ages other than newborn babies, here the reason is that a part of gut rotates on its own axis to twist and strangulate and under go necrosis & therefore septic shock (infection in this case ocuurs due to intestinal bacteria) occurs, results in death if not diagnosed & treated urgently.
So very sorry for your loss.
Sorry to hear that
I had a volvulus a long time ago and on my way from the helicopter to the hospital for surgery they naturally untwisted themselves
I was just diagnosed with Malrotation at the age of 48. I went to the ER with severe abdominal pain. Thankfully the rotation corrected itself. I will be having the LADD's procedure to help with the issues. This was a great video to explain it a little better!! Thank you!
thank you, amazing information.
AMAZING VIDEO and overview and a huge help in understanding and explaining a presentation I have to do on this topic. THANK YOU SO MUCH FOR UPLOADING!
I have malrotation and was Dx’d w hypermobile EDS (Ehler’s Danlos Synd.). This involves a variant of collagen & is likely under diagnosed. I’ve read before that those w malrotation are more likely to have h-EDS. Am wondering if anyone here has seen a correlation w EDS or other health issues.
Same thought, had volvulus twice and got a few symptoms of eds. Would be nice to know though we couldn't change much about it
Thank so much for the great video. :)
I appreciated the approach taken, there is a lot of confusion going around this subject.
Can a nonrotation be seen when doing a colonoscopy or an appendectomy? I had an upper GI in my late 30's and the doctor or technician showed me the x-ray before I even left the x-ray room. My large intestines were all on the left side. I was told it was just an unusual variation and not a problem. I had an appendectomy in my late 60's because of a polyp that was too close to the appendix to remove during the colonoscopy. Both doctors said they did not see any indications of a nonrotation. Is this possible? Can nonrotation cause chronic constipation?
Same problem here... I was born with ladds bands, they operated at 3 weeks (twice) and my report says I had malrotation.. Im 48 now, and 10 years ago I had imaging, CT scan, etc done, and my gut looks like non rotation, my intestine all on the left side... Constantly, all day I think about vacating my bowls for relief. Saw a specialist, and he said ibs... Fodmap diet seems to help a bit... Looking for a support group... Have you found any? Have you found a solution to your constipation?
There has been new research published regarding a new surgical procedure by Dr. Kareem Abu-Elmagd from the Cleveland Clinic, which has been approved by the American Surgical Association. This video is great, but a bit out of date due to this new paper published in the Oct 2021 of Surgical Annals. Med students - heads up, you need more up to date info, as this condition is usually misdiagnosed as other conditions, and Ladds surgery is no longer the gold standard.
really well explained looking forward to your next videos
Two years ago, at the age of 33, I was in the ER over some kidney stones. A CT Scan was done, the doctor came back and said yes you do have stones but did you know you have malrotation of the midgut. I was shocked. Thinking back, I have always been symptom free but wonder do I need to have this corrected? (Ladd's procedure) Or could the surgery cause more harm than good? Obviously now, any stomach ache or missed bowel movement makes me super paranoid. There just isn't much info on this regarding adults as most are diagnosed as infants. Any info/suggestions are appreciated.
Ultrasound is used to screen..to look for SMA-SMV axis or any whirlpool sign( suggestive of volvulus). Upper gastrointestinal contrast study is diagnostic
I wonder the same thing, I'm almost 22 and was diagnosed with it when I went to the ER for stomach pain at 16, they said they couldnt even see one of my intestine in the scan (I dont remeber if it was small or large) I had both a CT Scan and an Ultra Sound done but honestly I don't remember much of what they told me except to eat healthy.
I suspect I might have become Anemic because of it, but it's hard to tell because I have menstral cycles so I couldn't say for certain
@@sevprogramming I have surgery for Malrotation. Several surgeries actually
I’m 71 didn’t know ANYTHING about malrotation. Until, one early morning the pain woke me up. The VA hospital here fixed me,(removed ascending colon), But they had to “go to school”, to learn how. My gut still isn’t “normal”, I cannot depend on being able to go for a car or plane ride without worry . It’s been 6 months. But…………
great content! love the structure of these videos
I’m home from the hospital with massive upper left abdomen pain. They thought a hernia was happening up there but they told me I have a Malrotation of my small intestines.
I am 32. I’m on strict no moving orders to heal for a week. Then supposed to see a doc.... should I reach out to a specialist
My son has also this problem.Two times surgery done.Always I feel why this is done.
It’s interesting because I was told I had non rotation but I’d had both volvulus and obstruction (of the duodenum and somewhere else that I can’t remember) caused by the Ladd bands
my son has that problem question howlong it takes the surgery
how is he niw
@@saqisaqi1585 he has four years old right now is in treatment pending surgery but doctor says is very complicated just medication for now and probiotics not more pain for now he is eating great like i said he is in treatment now very expensive and doctors appointment every two month but he can have an emergency because his intestines can have obstruction and can die hope not but we are aware of that in case he has a very strong pain we have to run to the hospital immediately thanks for asking
@@362herbert even my son have same condition he is just 50 days old
@@362herbert may Allah give him good health
@@saqisaqi1585 sorry to hear that
MY WIFE GOING TO HAVE THAT SURGERY AND SHE SO SCARED AND BEEN IN TEARS
thanks ,please can you tell me what logiciel you use.
Thank you this was really helpful!
❤👌
this was so helpful!!! thank you!!!
Thank you for your work. It is pretty straightforward only after your explanations though😅
You're welcome 😊
I have a newborn with mal rotation is it life threatening she's abl to hld down food and poops normally is that a good sign? ??
Kalani Toki Normal bowel movements is definitely a good sign. However, if not treated the condition can worsen and then become potentially life threatening. If not already, you should be seeing a pediatric specialist to develop a management plan specifically to your child.
What’re the chances of volvulus with non rotation
good question. I think its less. Because after the Ladds surgery the gut is left in a non rotation position I believe ? Which is said to lower the risk of volvulus ?
can the spleen be affected by Volvulus?
Thank you very much
I have Q!! In ladd's producure..do we place the small bowel in the right side and the large bowel in the left of the abdomen?!!!
no
Yes
The Ladd's band's are released, mesentery widened, duodenum mobilized. Finally appendectomy done. Followed by placement of caecum in left hypochondrium and small intestines on right side.
Thank you so much
awesome class! thanks :)
+roshni s Your Welcome
Thank you Sir! ✨
very simple and nice explaination.
More than great!
amazing!!! Thanku sir! 💯
your work is highly appreciated Sir. thank you sooo much
So nice of you
Tmkc
Thank you !
Thank you
I had it when I was 2 is there a chance it could happen again??
Yes and no, it depends, I know this, because I had it when I was just 2 weeks old, and when I was about 11 years old, the second time was worse, but don't let that scare you.
The chances of it happening again is really really small, I was just unlucky when I was cured form the 1st time, my Intestines Were not laid out in the right way
Great video. Thanks.
Fantastic
Thank you so much for your effort! That was quite helpful.
Glad it helped!
Intersting information sir!
Glad you think so!
thak youuu that was helpful
Glad it helped!
Excellent 👌
thank you so much
Your Welcome. Glad you enjoyed!
🏅
Thank you so much, it's really helpful.
Awesome tutorial, very thorough and well explained, thanks man! BTW what device do you use for the video, a Microsoft Surface?
MrAliMcB Yeah I use the Microsoft Surface - a truly amazing device.