What are the key differences in intestinal malrotation between adults and neonates?

Intestinal Malrotation: Key Differences Between Adults and Neonates

Intestinal malrotation is a congenital anomaly that presents differently in neonates versus adults, with neonates typically manifesting acute, life-threatening symptoms requiring immediate surgical intervention, while adults often present with chronic, vague abdominal complaints that may go undiagnosed for years. 1

Pathophysiology and Embryology

Intestinal malrotation occurs due to disruption in normal embryological development of the bowel, resulting in abnormal positioning of intestinal segments and their mesenteric attachments. The key anatomical findings include:

• Abnormal position of the duodenojejunal junction (ligament of Treitz)
• Abnormal location of cecum and ascending colon
• Presence of Ladd's bands (peritoneal bands crossing the duodenum)
• Narrow mesenteric base predisposing to volvulus

Clinical Presentation: Neonates vs. Adults

Neonates

• Timing of presentation: Typically within first days or weeks of life 1
• Cardinal symptom: Bilious vomiting (hallmark sign requiring urgent evaluation) 1
• Presentation pattern: Acute and dramatic
• Common findings:
  • Bilious vomiting in first 2 days of life
  • Double bubble sign on imaging
  • Midgut volvulus as a life-threatening complication
  • Abdominal distension
  • Feeding intolerance

Adults

• Timing of presentation: Can remain asymptomatic until adulthood 2, 3
• Cardinal symptoms: Chronic, vague, non-specific abdominal complaints 4
• Presentation pattern: Often chronic, intermittent symptoms for years 2
• Common findings:
  • Recurrent abdominal pain
  • Intermittent bowel obstruction
  • Chronic malnutrition
  • May be discovered incidentally during imaging or surgery for other conditions 2
  • Can present acutely with bowel obstruction or volvulus 5, 6

Diagnostic Approach: Neonates vs. Adults

Neonates

• Initial imaging: Abdominal radiographs (may show double bubble or obstruction pattern) 1
• Gold standard: Upper GI series (96% sensitivity) 1
  • Abnormal position of duodenojejunal junction is diagnostic
• Ultrasound findings: Whirlpool sign (specific for volvulus), abnormal SMA/SMV relationship 1
• High clinical suspicion: Any neonate with bilious vomiting requires urgent evaluation 1

Adults

• Diagnostic challenges: Often misdiagnosed due to vague symptoms 2, 4
• Imaging modalities: CT scan with contrast more commonly used in adults 2
• Diagnostic findings: Mesenteric swirling, abnormal position of bowel segments 2
• Incidental discovery: May be found during surgery for other conditions 5

Management Differences

Neonates

• Urgency: Requires immediate surgical intervention when symptomatic 1
• Standard procedure: Ladd's procedure (division of bands, placement of small bowel on right, large bowel on left) 1
• Mortality risk: High if volvulus with bowel ischemia occurs 1

Adults

• Surgical approach: May require more extensive procedures if chronic inflammation or adhesions present 5
• Complications: Higher risk of enterotomy during laparoscopic approach due to adhesions 2
• Outcomes: Generally good relief of symptoms after surgical correction 2, 4

Common Pitfalls in Diagnosis

1. In neonates:

   • Failure to recognize bilious vomiting as a surgical emergency
   • Misinterpreting normal radiographs (present in 56% of cases requiring surgery) 1
   • Relying solely on SMV/SMA relationship on ultrasound (has false negatives) 1

2. In adults:

   • Attributing chronic symptoms to functional disorders
   • Failure to consider malrotation in adults with recurrent, unexplained abdominal pain 2, 4
   • Not investigating abnormal appendix location during appendectomy 2

Key Points to Remember

• Malrotation with volvulus is a surgical emergency at any age
• Adults with malrotation may have suffered symptoms for decades before diagnosis 2, 4
• Upper GI series remains the gold standard for diagnosis in both populations 1
• Surgical correction is indicated even in asymptomatic patients due to lifetime risk of volvulus 6