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Gut. 2007 November; 56(11): 1598.
PMCID: PMC2095670

EDITOR'S QUIZ: GI SNAPSHOT

Answer

From question on page 1589

The patient's barium meal shows her small bowel lying to the right of the midline with the caecal pole in the left upper quadrant. This confirmed the diagnosis of congenital malrotation of the bowel. Transit of barium was delayed at the third part of the duodenum raising the suspicion of an obstructing Ladd band causing her vomiting and weight loss.

At laparotomy (fig 11)) the entire duodenum was intraperitoneal but fixed by multiple adhesive bands from the liver to the caecum. The caecum was lying to the left of the midline, while the pylorus was in the midline. All adhesive (Ladd) bands were divided to free the duodenum. The jejunum and caecum were fixed to the anterior abdominal wall in a bid to prevent future volvulus and an appendicectomy was carried out.

figure gt105585a.f1
Figure 1 At laparotomy.

Congenital midgut malrotation is estimated to occur in 1/200–1/500 live births. In the majority of cases it presents acutely before the age of 1 with volvulus. In older children and adults, the clinical presentation is more variable and insidious. The end result is that the caecum ends up in the mid‐upper abdomen and is fixated to the abdominal wall by bands of peritoneum. These bands of peritoneum, called Ladd bands, cross the duodenum and can cause extrinsic compression and obstruction of the duodenum. Congenital midgut malrotation should be considered in all cases of persistent vomiting.


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