Bheesham D. Dayal, BSc is a fourth-year medical student at Windsor University School of Medicine, St. Kitts and Nevis, West Indies. Nida Blankas-Hernaez, MD, FAAP, is an Associate Professor with the Department of Pediatrics, Lutheran General Hospital, Park Ridge, IL.
Mr. Dayal and Dr. Blankas-Hernaez have disclosed no relevant financial relationships.
Address correspondence to: Nida Blankas-Hernaez, MD; fax: 847-972-1926; email: firstname.lastname@example.org.
A previously healthy 16-year-old girl was admitted to the emergency room and ultimately to the hospital floor with a 1-day history of severe abdominal pain. Her past medical history consisted of intermittent abdominal pain for 6 years without any identifiable cause. She had no changes in bowel habits or history of abdominal surgery, and her family history was negative for any gastrointestinal diseases. Two days before presentation, she presented to our office with dysuria and lower abdominal pain, and sulfamethoxazoletrimethoprim was begun after urinalysis and urine culture were performed. The urinalysis showed a trace of blood, but was otherwise normal. The culture ultimately was negative.
The patient’s symptoms improved at first, but 1 day after she started taking the antibiotics, she developed severe abdominal pain and vomiting. She went to the emergency department, where intravenous fluids were administered along with an antiemetic (ondansetron). On physical examination, the patient’s vital signs were as follows: temperature 97.8°F, pulse 86/min, blood pressure 115/77 mm Hg, and respiratory rate 24 breaths/min. She was a normally developed girl who appeared uncomfortable but was in no acute distress. Her abdomen was soft without distention, and she exhibited no peritoneal signs. Normal bowel sounds were auscultated. There was notable tenderness to palpation, especially over the epigastrium, the left periumbilical area, and her left and right flanks. In addition, there was also mild tenderness over McBurney’s point, but obturator, psoas, Murphy, and Rovsing signs were all negative. The remainder of the examination was unremarkable. Her rectal examination was normal and pregnancy test was negative. Hemoglobin, white blood cell count, and basic chemistry panel were all within normal values. Urinalysis showed negative nitrates and leukocyte esterase; however, there were a few bacteria present with one to five squamous epithelial cells; one to five WBC; and one to two red cells. For her presumed urinary tract infection, the antibiotic was continued. A computerized tomography (CT) scan of the abdomen and pelvis with oral and intravenous contrast and upper GI with contrast (see Figure 1) were obtained and revealed the diagnosis.
Finally, malrotation can be diagnosed on CT by the anatomic location of a right-sided small bowel, a left-sided colon, aplasia of the pancreatic uncinate process, or an inverse relationship of the superior mesenteric vessels (Figure 1, see page 9).9 The superior mesenteric vein is normally located to the right of the superior mesenteric artery, but the relative positions of the vein and artery are reversed in approximately 60% of patients with malrotation.10
However, abnormalities of SMASMV orientation are not entirely diagnostic because some patients with malrotation have a normal relationship, whereas an inverted relationship can also be seen in patients without malrotation.9,10 Therefore, an upper GI contrast series remains the gold standard for diagnosing intestinal malrotation.
The classic treatment for intestinal malrotation is the Ladd procedure. It involves counterclockwise reduction of the volvulus if present, division of any coloduodenal bands, widening of the mesenteric base to prevent repeated volvulus, and prophylactic appendectomy.11 Generally, symptomatic patients with malrotation require surgical intervention. Management of asymptomatic patients discovered incidentally to have malrotation is more controversial, although some surgeons recommend that all patients with malrotation receive laparotomy.12
On hospital day 2, the patient underwent a Ladd procedure to correct her malrotation, along with…