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Nonrotation of the bowel with inflamed appendix. By

Nonrotation of the bowel with inflamed appendix. By Dr. feras baquein Dr. Mahmoud zaaterh. Case presentation.

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Nonrotation of the bowel with inflamed appendix. By

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  1. Nonrotation of the bowel with inflamed appendix. By Dr. ferasbaquein Dr. Mahmoudzaaterh

  2. Case presentation A 16 years old female patient, presented to E.R. in Luzmila hospital on 20.12.2011 with vague abdominal pain of one day duration associated with nausea and vomiting 3 times, but no diarrhea. • No H/O pervious operation or serous illness. • Family history :free

  3. She is single ,the L.M.P. in 12.12.2011 On physical examination: • A febril, not dyspnic .Head and neck free. • Good air entery. • Abdomen not distended ,moving well with respiration,bowel sounds audible • Hernial orifices free .Mild tenderness at both iliac fossa, with mild rebound tenderness at Rt. I.F. Rovsing sign positive. • Abdominal U/S: reported simple cyst at Lt.ovary with enlarged mesenteric lymph nodes in the RIF. • Chest X Ray, abdominal C.T.scan done.

  4. Laboratory Result: • Hemoglobin: 13.5gm/dl • Hematocrit:0.39 • Leucocytes:17000 • Differential: • Neutrophiles:94% • Lymphocytes:4% • Monocytes:2% • Platelets:266000/dl • Random blood glucose:107mg/dl • Urea:31mg./dl • Creatinine:0.6mg/dl • Electrolytes: • Na:136mmol/l • Potassium:4mmol/l • Cloride:108mmol/l • Urine analysis:free • Appendicectomy through infra umbilical midline incision was done.

  5. Findinges: Lt.sidedphlegmanous appendix with non rotation of the bowel with mesenteric lymphnodes and follicular cyst in the LT ovary.

  6. Definition of Malrotation • Malrotation is a congenital abnormal position of the bowel within the peritoneal cavity and usually involves both the small and the large bowel. • Malrotation is accompanied by abnormal bowel fixation by mesenteric bands or absence of fixation of portions of the bowel, leading to increased risks of bowel obstruction, acute or chronic volvulus, and bowel necrosis.

  7. Definition of Malrotation • The term malrotation applies to a wide range of intestinal anomalies, from a readily apparent omphalocele in newborns to asymptomatic nonrotation of the large and small bowel in adults. Most people who are affected by malrotation show signs of the condition soon after birth; however, malrotation in a minority of cases is diagnosed long after infancy and is not manifested by the typical clinical sign of bilious vomiting.

  8. Definition of Malrotation • In nonrotation, a subtype of malrotation associated with a lower risk of volvulus, the small bowel is located predominantly on the right side within the peritoneal cavity and the colon is located on the left side.

  9. Embryologic Origins • The gut develops from the yolk sac, which divides into three sections early in development: the fore-gut, which is supplied by the celiac artery; the midgut, which extends from the middle third of the duodenum to the distal transverse colon and which is supplied by the superior mesenteric artery; and the hindgut, which is supplied by the inferior mesenteric artery.

  10. Pathology • During normal embryogenesis the bowel herniates into the base of the umbilical cord and rapidly elongates. As it returns to the abdominal cavity it undergoes complex ~270 degree counter clockwise rotation resulting in the duodeno-jejunal (DJ) flexure normally located to the left of the midline, at the level of L1 verterbal body and the terminal ileum located in the right iliac fossa. This results in a broad mesentery running obliquely down from the DJ flexure to the caecum, and prevents rotation around the superior mesenteric artery (SMA) .

  11. Embryologic Origins • In malrotation this does not occur and as a result the mesentery has a short root, which allows it to act as a pedicle (through which the SMA and SMV pass) around which volvulus can occur. 

  12. Intestinal malrotation is a congenital abnormality seen in up to 1:6000 live births 5. It is also frequently (~50%) associated with other abdominal anomalies, some of which are causative and others merely associated. These include 5:  • duodenal atresia / stenosis / web • congenital diaphragmatic herniation • gastroschisis • omphalocele • heterotaxy: 70% of individuals will have malrotation • choanalatresia

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