Malrotation of the gut manifested during pregnancy.
Department of Surgery, Seth G. S. Medical College and K. E. M. Hospital, Parel, Mumbai - 400 012, India., India
J V Hardikar
Department of Surgery, Seth G. S. Medical College and K. E. M. Hospital, Parel, Mumbai - 400 012, India.
The diagnosis of intestinal obstruction during pregnancy poses problems, as vomiting which is an important symptom of the obstruction can be attributed to hyperemesis of pregnancy and radiological investigation are avoided during this period. A case of intestinal obstruction due to volvulus resulting from congenital malrotation of the gut is reported here. The patient first presented during pregnancy. The case emphasises the need for thorough investigations in a case of persistent vomiting in pregnancy.
|How to cite this article:|
Hardikar J V. Malrotation of the gut manifested during pregnancy. J Postgrad Med 2000;46:106-7
|How to cite this URL:|
Hardikar J V. Malrotation of the gut manifested during pregnancy. J Postgrad Med [serial online] 2000 [cited 2020 Mar 31 ];46:106-7
Available from: http://www.jpgmonline.com/text.asp?2000/46/2/106/302
Intestinal obstruction can occur during pregnancy. Many a times, the diagnosis is delayed as commonly occurring condition like hyperemesis gravidarum is considered as the cause of the clinical features and secondly, the radiological investigations are not carried out during the early pregnancy for the fear of the foetal damage. Volvulus is responsible for intestinal obstruction occurring during pregnancy in 25% of the cases. Recently, we have encountered a rare case of volvulus due to malrotation, which manifested for the first time in life during her first pregnancy.
A 23-years-old primigravida, who delivered a full term baby 15 days ago, was referred for persistent vomiting and prerenal azotaemia. The patient had frequent attacks of vomiting, since the first trimester of the pregnancy. She was examined during pregnancy by a medical gastroenterologist for persistent vomiting who did upper gastrointestinal endoscopy, which showed duodenitis. She was given symptomatic treatment to which she did not respond. She continued to have episodes of vomiting throughout her pregnancy.
On examination, she was dehydrated. Her investigations revealed increased blood urea nitrogen and creatinine levels. The clinical diagnosis of high small bowel obstruction was made. She was given intravenous fluids and nasogastric tube was inserted, which recovered a large volume of bile (>1000 cc in the first 24 hours). Barium meal study showed obstruction to the junction of the second & third portion of the duodenum [Figure:1]. There was a suspicion of malrotation as indicated by sudden cut off at the junction of the second & third part of the duodenum with the birdís beak appearance.
After the fluid resuscitation, the patient was explored by a midline incision. On exploration, there was malrotation with volvulus of the small bowel at the level of the duodenum. The caecum and the ascending colon were mobile with presence of mesentery. There were bands across the duodenum and the ascending colon reaching the lateral abdominal wall. The rest of the viscera were normal. The uterus was in the process of involution.
After the division of bands of Ladd and derotating the volvulus the duodenal obstruction was relieved. The bowel got straightened out. The caecum and the ascending colon were repositioned on the left side. The appendix was removed to prevent diagnostic confusion, should she develop appendicitis in future, as the position of appendix was changed. The postoperative period was uneventful. On follow-up she was symptom free.
Intestinal obstruction in pregnancy is rare. Major causes of intestinal obstruction in the pregnant women include adhesions, volvulus, and intussusception. Volvulus of the small bowel is responsible in 25% of the cases, which is the commonest precipitating factor. Intestinal volvulus is responsible for 25% of acute bowel obstructions in pregnant women but only 3-5% in non-pregnant patients. The malrotation of the bowel makes it susceptible for volvulus. The mortality rate is higher during pregnancy than in the general population and applies to maternal and foetal as well. Even though, nausea and vomiting are common symptoms during pregnancy, persistent vomiting after the first trimester of pregnancy should be considered an alarming symptom, which always requires further investigation. A high index of suspicion is needed, and investigations for intestinal obstruction should be done, especially when abdominal pain and vomiting persist.
The author wishes thank the Dean, Seth G. S. Medical College and K. E. M. Hospital, for permitting to publish this case report.
Ventura-Braswell AM, Satin AJ, Higby K. Delayed diagnosis of bowel infarction secondary to maternal midgut volvulus at term. Obstet Gynaecol 1998; 91:801-810.|
|2||Damore LJ 2nd, Damore TH, Longo WE, Miller TA. Congenital intestinal malrotation causing gestational intestinal obstruction. A case report. J Reprod Med 1997; 42:805-808.|
|3||Lopez Carral JM, Esen UI, Chandrashekar MV, Rogers IM, Olajide. Volvulus of the right colon at pregnancy. Int J Clin Pract 1998; 52:270-271.