[size=20px]A sixteen-year old presents with chronic abdominal complaints. Which of the following is true regarding intestinal malrotation diagnosed beyond infancy?

 

A most patients can expect resolution of symptoms with Ladd procedure

 

B midgut volvulus at the time of presentation is more common than in infants

 

C computerized tomography scans will be nondiagnostic

 

D the likelihood of volvulus later in life can be predicted

 

E vomiting is the most common symptom[/size]

E

correct answer

A most patients can expect resolution of symptoms with Ladd procedure

 

Intestinal malrotation most frequently presents with bilious vomiting as an infant. Because most of the literature concerns this more common scenario, the management of patients with malrotation identified later in life remains controversial. Autopsy studies indicate that the prevalence of intestinal rotational abnormalities may be as high as one percent. Because most will remain asymptomatic - depending on the thoroughness of the obtained history - many suggest conservative management of malrotation when discovered as an incidental finding.

 

For older patients, abdominal pain, often chronic, is the most common presentation. Less common symptoms include nausea, often nonbilious vomiting, diarrhea, and weight loss. Beyond infancy, 88% can expect resolution of their symptoms following Ladd procedure.

 

The incidence of volvulus at the time of presentation decreases but does not disappear with age (12% in adults). Older patients are more likely to have a delay in diagnosis and a more complicated postoperative course when operated on emergently.

 

Although upper gastrointestinal series remains the gold standard for the diagnosis of intestinal malrotation, an increasing number of older patients have the diagnosis made by computerized tomography that identifies an abnormal bowel position and reversed relationship between the superior mesenteric artery and vein.

 

Patients with incidentally discovered malrotation should be questioned carefully and a Ladd procedure suggested if symptoms exist. Truly asymptomatic patients should be counseled regarding the unpredictable nature of catastrophic midgut volvulus later in life and offered Ladd procedure to decrease this risk.

E