McMahon Ellen, Penfold Michael, Cain Meghan
Vanderbilt University Medical Center, Division of General Pediatrics, Department of Pediatrics, Nashville, Tennessee.
Mayo Clinic, Department of Pediatrics, Rochester, Minnesota.
Clin Pract Cases Emerg Med. 2022 Feb;6(1):53-56. doi: 10.5811/cpcem.2021.11.52611.
Congenital bowel malrotation resulting in midgut volvulus is traditionally regarded as a diagnosis of infancy. Rarely, congenital bowel malrotation is diagnosed in adolescents or adults and requires a high index of suspicion. Presentations can be acute or chronic, and physical examination findings are nonspecific. Diagnosis is primarily achieved through abdominal computed tomography (CT) or during exploratory laparotomy. The pathophysiology in late-onset malrotation is similar to neonatal malrotation, with a division of Ladd's bands - peritoneal fibrous bands that connect the cecum to the right lower quadrant retroperitoneum - as the definitive treatment. We present a case of congenital bowel malrotation in an adolescent with persistent and worsening migratory abdominal pain.
An 18-year-old female presented to the emergency department with two days of poorly localized abdominal pain and nausea. Initial evaluation was unremarkable and she was discharged home with a diagnosis of constipation. She returned two days later with worsening abdominal pain and new onset emesis. Given her persistent and worsening symptoms an abdominal CT was performed, which revealed malrotation of the bowel. Taken together, her CT findings and abdominal symptoms were concerning for symptomatic congenital bowel malrotation and she underwent a Ladd procedure. She remained asymptomatic both at discharge and at two-week postoperative follow-up.
Symptomatic congenital bowel malrotation is more common in older children and adults than has traditionally been thought. Physicians must consider this diagnosis in their differential when working up a patient for acute or chronic intermittent abdominal pain to prevent potentially severe sequelae.
先天性肠旋转不良导致中肠扭转传统上被认为是婴儿期的诊断。很少有先天性肠旋转不良在青少年或成人中被诊断出来，这需要高度的怀疑指数。临床表现可以是急性或慢性的，体格检查结果不具有特异性。诊断主要通过腹部计算机断层扫描（CT）或在剖腹探查术中实现。迟发性旋转不良的病理生理学与新生儿旋转不良相似，以Ladd束（连接盲肠与右下腹腹膜后的腹膜纤维束）的分离作为明确的治疗方法。我们报告一例青少年先天性肠旋转不良病例，其有持续性且逐渐加重的游走性腹痛。
一名18岁女性因两天来腹部疼痛部位不固定和恶心就诊于急诊科。初始评估无异常，她被诊断为便秘后出院。两天后她因腹痛加重和新出现呕吐症状再次就诊。鉴于其持续且加重的症状，进行了腹部CT检查，结果显示肠旋转不良。综合其CT表现和腹部症状，考虑为有症状的先天性肠旋转不良，她接受了Ladd手术。出院时及术后两周随访时她均无症状。
有症状的先天性肠旋转不良在大龄儿童和成人中比传统认为的更常见。医生在对急性或慢性间歇性腹痛患者进行检查时，在鉴别诊断中必须考虑到这一诊断，以预防潜在的严重后果。
