Volvulus presents most commonly duringthe first year of life and fetal - PDF document

Volvulus presents most commonly duringthe first year of life and fetal intestinal volvu-lus is extremely rare. Prenatal visualisation ofvolvulus with ultrasound have been reported inonly few cases. It should be suspected an-tenatally when polyhydramnios, intestinal di-latation, ascites and/or signs of fetal anemia. The definitive diagnostic sign ofmidgut volvulus is the whirlpool signthat is pro-duced by the bowel loop and its accompanyingmesentery and mesenteric vessels that wraparound the main SMA. In our case, we demon-whirlpool signin pre-Fetal midgut volvulus is a life threatening con-dition that may be associated with hydrops fetal-is, spontaneous abortion, preterm delivery, fetalgrowth restriction and intrauterine fetal deathThe outcome depends on the amount of the com-promised part of the intestine and the gestationalage at the time of the event. Acute surgical man-agement is necessary for the necrotic part of theintestine. In this report, we present a case with anintrauterine midgut volvulus detected sonograph-ically at the antenatal period. Acute surgicalmanagement was performed soon after the birthwhich lead excellent prognosis.ReferencesAM, Ztine. World J Surg 1993; 17: 326-331.. Malrotation of themidgut in infants and children: a 25-year review.Arch Surg 1981; 116: 158-160.URLBAW. De-layed return of the fetal midgut to the abdomenresulting in volvulus, bowel obstruction, and gan-grene of the small intestine. J Ultrasound Med1992; 11: 233-235.V, TE, T. Prenatal diagnosis of gastrointestinalobstruction: a correlation between prenatal ultra-sonic findings and postnatal operative findings.Prenat Diagn 1993;13: 629-632.. Prenatal diag-nosis and management of congenital volvulus.Pediatr Radiol 1993; 23: 601-602.M, Z. Early sonographic de-tection of fetal intestinal obstruction and possiblediagnostic pitfalls. Prenat Diagn 1996; 16: 203-JP, SL, GG, TVA, MORAYP, LUltrasound diagno-sis of midgut volvulus: the “whirlpool” sign. PediatrRadiol 1992; 22: 18-20.Y, AT, TORITANIT, OE, KHIBATAOZAWAHKAWARAIRATAClockwise whirlpool signat color Doppler US: an objective and definitesign of midgut volvulus. Radiology 1996; 199:M, BASZCZYSKIJ, GJ, JA, S. Congenital midgut volvulus associated with fe-tal anemia. Fetal Diagn Ther 2010; 28: 119-122.. Intestinal atresia, stenosis, and malro-tation. In: Behrman RE, Kliegman RM, JensonHB, eds. Nelson textbook of pediatrics, ed 16.Philadelphia: WB Saunders, 2000; pp. 1132-1136 KW, CSY, S. Defini-tive diagnosis of intestinal volvulus in utero. Ultra-sound Obstet Gynecol 1999; 13: 200-203.. Fetal midgutvolvulus presenting at term. J Pediatr Surg 1999;34: 1280-1281.T, KITANOY, HT, SAYASHI. P

renatal diagnosis and management ofabdominal diseases in pediatric surgery. J PediatrSurg 2004; 39: 1819-1822.S, K. Ischaemic haemorrhagic necro-sis of the intestine secondary to volvulus of themidgut: a silent cause of intrauterine death. J Ob-stet Gynaecol 2004; 24: 310.Y. Yilmaz, G. Demirel, H.O. Ulu, I.H. Celik, O. Erdeve, S.S. Oguz, U. Dilmen Urgent surgical management of a prenatally diagnosed midgut volvulus with malrotation During embryonic development, the gut tubeelongates from the stomach to the rectum and itprogressively protrudes into the umbilical cord.As the organs develop, the midgut loop rotatesanticlockwise around the axis of SMAwhich brings the duodeno-jejunal loop to theright and the ceco-colic loop to the left side be-tween the 6th and 10th weeks of fetal develop-ment and afterwardsintestines return to the in-traabdominal position by the 10th week of em-bryonic life. The proximal and distal loops un-dergo a further 180°of anticlockwise rotation, atotal of 270°rotation and as a result the duode-no-jejunal junction lies in the left upper quad-rant and the ileocecal junction in the right lowerquadrant of the abdomen.Midgut volvulus oc-curs when the intestinal loop suspending alongthe free margin of the mesentery twists aroundthe SMA. Volvulus is most often associatedwith malrotation that the short basal attachmentof the mesentery to the posterior abdominalwall in intestinal malrotation may be the predis-posing factor Figure 1. Figure 2.Ultrasonographic appearence of the cystic lesion. Figure 3.Abdominal tomography showing a heterogenous32 mm cystic lesion lying from the posterior level ofthe right lob of the liver to the level of umbilicus. Figure 4.Surgical exploration of the patient. Review for Midgut volvulus is a life-threat-ening condition that commonly presents duringthe first year of life rarely antenatally. Here we re-port successful urgent surgical management ofan unusual case with malrotation exhibiting thesonographic findings of volvulus in utero thatleads to premature birth. This 34-wk, 2700 g in-fant was born via spontaneous vaginal delivery.Prenatal ultrasound showed polyhydramniosand 30 x 40 mm cystic lesion showing whirlpoolsign in abdomen that made us think midgutvolvulus. The patient had distended abdomenwith skin discoloration. An emergency surgicalmanagement was performed showing malrota-tion, volvulus and a 15 cm ischemic necrotic re- IntroductionMidgut volvulus is a life-threatening conditionin which the small bowel or proximal colontwists around the superior mesenteric artery(SMA) and it commonly presents during the firstyear of life. Prenatally diagnosed cases havebeen reported in

the literature, 25% of them maybe complicated due to ischemic necrosisdiagnosis of midgut volvulus in infants is facili-tated by direct sonographic visualization of thetwisted bowel loop but antenatal diagnosis isvery difficult. Here we report successful surgi-cal management of an unusual case with malrota-tion exhibiting the sonographic findings ofvolvulus in uteroA 25-year-old pregnant woman was on follow-up in our Center during her pregnancy and noproblem was reported up to 34when she admitted to the Hospital because of Urgent surgical management of a prenatally diagnosed midgut volvulus with malrotation Y. YILMAZ, G. DEMIREL*, H.O. ULU, I.H. CELIK*, O. ERDEVE*,Pediatric Surgery Division and *Neonatology Division; Zekai Tahir Burak Maternity Teaching Hospital,Ankara, Turkey. °Department of Pediatrics, Yildirim Beyazit University, Ankara, Turkey Gamze Demirel, MD; e-mail: kgamze@hotmail.compreterm delivery. Prenatal ultrasonography per-formed just before the delivery revealed polyhy-40 mm cystic lesion withwhirlpool sign in abdomen that made us thinkmidgut volvulus. A 2700 g male infant was bornon the same day with spontaneous vaginal route.Apgar scores were 5 and 7 after 1 and 5 minutes,respectively. Positive pressure ventilation wasperformed at the delivery room and afterwardstransported to neonatal intensive care unit(NICU). Oxygen therapy was given with hood.Initial laboratory values included a white bloodcell count of 73.000/mm, hematocrite 38%,aplatelet count of 140.000/mmsmear revealed 80% normoblast, C-reactive pro-tein level 39 mg/dl, Interleukin-6 level 220pg/ml. Blood gas values were normal. A plainsupine abdominal graphy did not demonstratebowel gas, except in stomach. EmpiricalPeni-cillin G and netilmycine therapy were begun andoro-gastric decompression was performed. Acutesurgical management was planned after the he-modynamic stabilization of the infant. The ab-domen was distended markedly and there was a(Figure 1). Immediate ultrasonography and ab-dominal tomography were performed just beforethe surgery and revealed a heterogenous 47 mm cystic lesion lying from the posterior level ofthe right lob of the liver to the level of umbilicus(Figures 2 and 3). Surgical exploration revealedmeconium in abdomen, a volvulus of small bow-el with extensive necrosis and perforation at apart of 15 cm of terminal ileum and intestinalmalrotation (Figure 4). After detection of midgutvolvulus, the involved loop was resected and theand double-lumened stomy was constructed atthe right lower quadrant. The patient recoveredrapidly and was discharged home on 10ter surgery. Osteomy was closed on sixth month. 2012; 16(4 Suppl): 52-