Nonrotation of the
bowel with inflamed
appendix.
By
Dr. feras baquein
Dr. Mahmoud zaaterh
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
 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.
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.
• Findinges: Lt.sided
phlegmanous appendix with
non rotation of the bowel with
mesenteric lymphnodes and
follicular cyst in the LT ovary.
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.
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.
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.
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.
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 duodenojejunal (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) .
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.
• 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
• choanal atresia