Radiological versus clinical evidence of malrotation, a tortuous tale--10-year review

Malrotation is a common abnormality, often diagnosed in the neonatal period. Symptoms may be nonspecific and clinical signs of volvulus are often only seen in the late stages when there has been significant ischemic insult to the bowel. The gold standard diagnostic investigation is the upper gastrointestinal (UGI) contrast study. This study was designed to assess the incidence of negative laparotomy in patients with malrotation diagnosed on UGI contrast study and to identify the clinical signs and symptoms at presentation.

A retrospective review of patients who underwent laparotomy for malrotation, over a 10-year period (2001 to 2010) was performed. Inclusion criteria were patients<16 years of age with a diagnosis of malrotation on preoperative UGI contrast study.

A total of 72 patients were reviewed. UGI contrast study diagnosed 43(60%) cases of malrotation without volvulus, and 29(40%) cases of malrotation with volvulus. Laparotomy revealed that 39(54.2%) patients had malrotation without volvulus, 27(37.5%) had malrotation with volvulus, and 6(8.3%) had no evidence of malrotation. A total of 13(18%) patients had an incorrect diagnosis on UGI contrast study; 6(8.3%) had normal anatomy, 3(4.2%) diagnosed with malrotation without volvulus, had volvulus at laparotomy, and 4(5.5%) diagnosed with malrotation and volvulus had no volvulus at laparotomy.

UGI contrast study can occasionally be misleading. In the above study, we have shown that there is a significant rate of negative laparotomy following diagnosis of malrotation on UGI contrast study. Therefore, we would advocate that all parents of patients undergoing laparotomy for malrotation should be informed of the risk of negative laparotomy as part of the consent process.