Malrotation With Midgut Volvulus

  • Etiology: prerequisite is malrotation with narrow mesenteric root
  • AXR: usually unremarkable
  • UGI: malposition of duodenal-jejunal junction and often a spiral / corkscrew appearance to the duodenum / proximal jejunum which is a demonstration of the volvulized bowel
  • Treatment: Ladd’s procedure
  • Clinical: bilious vomiting is radiological and surgical emergency as strangulation sequence can happen in few hours: malrotation -> narrow mesenteric root -> volvulus -> venous obstruction -> continued arterial inflow -> venous congestion -> raised tissue pressure above blood pressure -> cessation of arterial flow / arterial obstruction -> midgut necrosis from jejunum to middle of colon

Cases of Malrotation With Midgut Volvulus

AXR of small bowel obstruction due to malrotation with midgut volvulus
AXR supine shows multiple dilated loops of bowel with thickened walls.
UGI of malrotation with midgut volvulus
Two AP images from an upper GI exam show the duodenal-jejunal junction to be to the left of the spine but to be low lying. The proximal jejunum has a spiral appearance.
Upper GI of malrotation with midgut volvulus
AP image from an upper GI (left) shows the ligament of Treitz projecting over the right pedicle of the L2 vertebral body and to be lower in position than the duodenal bulb that projects over the right pedicle of the L1 vertebral body. The spiral appearance of the proximal jejunum is best appreciated on the lateral image (right).
Upper GI of malrotation with midgut volvulus
AP image from an upper GI shows complete obstruction of the duodenum at the junction of the second and third parts of the duodenum and associated massive gastroesophageal reflux. A final image taken 5 minutes later was unchanged.
Upper GI of malrotation with chronic midgut volvulus
AP image from a small bowel follow through exam (below) shows the small bowel on the right side of the abdomen and the colon on the left side of the abdomen. Close examination of the upper GI portion of the exam (above) beyond the abnormal position of the ligament of Treitz shows a thickened appearance of the folds throughout the duodenum (above left) and proximal jejunum (above right) but there was no evidence of spiraling of the bowel or obstruction.
Surgical image
Surgical image shows the entire small bowel, from the jejunum to the terminal ileum, to be infarcted.