From the Research
Management of incidental findings of possible intestinal malrotation and appendiceal intussusception requires a careful approach based on patient symptoms and imaging findings, with asymptomatic adults typically undergoing observation and symptomatic patients requiring prompt surgical consultation. The approach to managing these conditions prioritizes minimizing morbidity, mortality, and optimizing quality of life. For asymptomatic adults with incidentally discovered malrotation, observation without surgical intervention is often appropriate, with regular follow-up every 6-12 months 1. However, if the patient experiences abdominal pain, vomiting, or other concerning symptoms, prompt surgical consultation is recommended.
Key Considerations
- For symptomatic patients, laparoscopic Ladd's procedure is the standard surgical approach, which involves division of abnormal peritoneal bands, widening of the mesentery, and appendectomy to prevent future diagnostic confusion.
- Regarding appendiceal intussusception, asymptomatic cases may be monitored with follow-up imaging in 3-6 months, while symptomatic cases typically require surgical intervention, usually appendectomy 2.
- Complete preoperative workup should include contrast-enhanced CT scan of the abdomen and pelvis to evaluate for volvulus or other complications.
- The management rationale stems from the understanding that while malrotation predisposes to midgut volvulus (a surgical emergency), many adults with malrotation remain asymptomatic throughout life 1.
- Similarly, appendiceal intussusception may resolve spontaneously in some cases but can lead to appendicitis or intussusception of larger bowel segments if symptomatic.
Diagnostic Approaches
- Ultrasonography (US) and Computed Tomography (CT) are relevant and complementary imaging techniques for establishing the diagnosis of acute appendicitis associated with malrotation 3.
- CT colonography (CTC) provides an ideal means for estimating the prevalence of intestinal malrotation in asymptomatic adults and can uncover unexpected cases of malrotation in adults, which may be relevant in terms of potential for future complications 1.
- The SMA-SMV relationship and the location of the ileocecal valve are important imaging findings to assess in cases of suspected malrotation 1.
Patient Education
- Patients should be educated about warning signs requiring immediate medical attention, including severe abdominal pain, bilious vomiting, and signs of bowel obstruction.
- Regular follow-up and monitoring are crucial for asymptomatic patients with malrotation or appendiceal intussusception to promptly address any emerging symptoms or complications.