Tuesday, February 23, 2010
Malrotation in the Adult
This was an interesting one. A middle aged woman presented to the hospital with a year and a half history of crampy abdominal pain and weight loss. The pain worsened right after eating and the only relief she could get was by vomiting. She had adjusted her diet such that she only ate small meals with soft foods like mashed potatoes and casseroles. Otherwise she was a very healthy, well adjusted female. Never had surgery before.
Now we see a lot of patients as consults who come in with these complaints of chronic vague abdominal pain and nausea. The work-ups usually end up going nowhere. Negative CT scan. Negative endoscopy. Negative ultrasound. They get diagnosed with Irritable Bowel Syndrome (IBS) and get sent home with a crazy concoction of IBS pharmacology. Surgeons don't like these referrals so much. Some might even use a phrase like "waste of time consult" while commiserating in the OR lounge. (Of course not me!)
So I reviewed this lady's case. Sure enough, she'd been admitted several times over the past year. Her radiographic imaging, up to that point, had always been negative. Her blood work was stone cold normal. So I went in see her thinking I'd cruise through a quick little interview. The exam was unremarkable. Nothing appeared awry. Her abdomen was absolutely benign. But something nagged at me. She just seemed so normal. Often times these patients with chronic abdominal complaints can be a handful to deal with. There's a psychosomatic component to their issues that is very hard to quantify. This lady on the other hand was pleasant and genuinely distressed by the symptoms she was having. She couldn't eat the way she wanted. She was losing weight. And the symptoms seemed to consistently occur whenever she ate a larger meal. So I ordered a small bowel follow through (radiology test where you swallow barium and a series of images are taken tracking the barium through your GI tract).
The SBFT showed external compression of the duodenum, suggesting a mechanical problem. Therefore I booked her for surgery, expecting to find either some form of congential malrotation or perhaps the SMA syndrome. Boom goes the dynamite on the malrotation diagnosis. Her duodenum was the size of a summer squash and there was this rat's nest of snarl on the right side of her abdomen involving the cecum, the mesenteric pedicle and the proximal jejunum, all abnormally affixed together. Bands of congential scar tissue had partially entrapped the duodenum with a resultant partial torsion of the mesenteric vessels. Her SMV, compensating for reduced return over the years, had swollen to a ropish diameter, like what you see in cirrhotics with portal hypertension. The operation to fix this, Ladd's Procedure, is actually quite cool. You divide all the bands, straighten out the mesentery, lyse interloop adhesions, and what you find once everything is freed up is that the cecum wants to lie on the left side of the abdomen. So you can perform a cecopexy, affixing the cecum to the parietal peritoneum under the spleen. You also take out the appendix because if the patient ever develops left upper quadrant abdominal pain in the future, appendicitis won't be suspected.
It's a fun operation. For some reason this was my third case of malrotation on an adult. Fortunately all worked out well. The lesson as always: listen to your patients, especially those who seem reasonable...