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DUODENAL ILEUS and INTESTINAL MALROTATION a Report on Two Cases Occurring in Adults R

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DUODENAL ILEUS and INTESTINAL MALROTATION a Report on Two Cases Occurring in Adults R POSTGRAD. MED. J. (I963), 39, 534 Postgrad Med J: first published as 10.1136/pgmj.39.455.534 on 1 September 1963. Downloaded from DUODENAL ILEUS AND INTESTINAL MALROTATION A Report on Two Cases Occurring in Adults R. A. ROXBURGH, M.B., BCh.(Cantab.), F.R.C.S., F.R.C.S.E. Lately Surgical Registrar, Central Middlesex Hospital, Park Royal, London, N. W. io THERE has been a tendency for many years now At least this was certainly true in the first case to relegate the concept of duodenal ileus in adults reported below and the measures taken on that to the limbo of forgotten things. Perhaps one occasion were impromptu; the second patient reason why the diagnosis is unfashionable is that also presented unexpectedly but by that time a those who suffer from the condition often belong study of the problems posed by the first case led to that unhappy band of wanderers whose com- to the operation being carried out in a more plaints of vague dyspepsia remain undiagnosed orthodox manner. after repeated barium meals and cholecystograms. From time to time some of these patients have a Normal Intestinal Rotation 'bilious attack' and when, after a few days, the For a full account of the rotation of the gut the attack subsides spontaneously the doctor may be reader is referred to the notable article by DottProtected by copyright. only too thankful and feel disinclined to investigate (1923) but for the moment Fig. i may help to the patient yet again for fear of making him still refresh the memory. The diagrams are intended more 'introspective'. to show how, with the aid of a couple of pipe The condition is one of extrinsic duodenal cleaners, one may demonstrate the fundamentals obstruction and Wilkie thought that it was due to of the mechanism of rotation of the midgut loop. the superior mesenteric artery being stretched Embryology does not lend itself to facile illustra- tightly across the duodenum. This theory has now tions and the model is not a perfect representation been largely discredited and replaced by one that of what happens but it nevertheless serves our postulates congenital bands as the obstructing present purpose well enough. agent; nearly always (89%, Louw, I960) these At the fourth week the enlargement of the intra- bands are associated with an anomalous rotation abdominal organs is so great that the gut is forced of the gut, and this in turn is frequently but by out through the umbilical orifice and into the no means invariably associated with a volvulus of umbilical sac as a physiological umbilical hernia. the midgut. Thanks largely to the work of Dott Rotation occurs partly there and partly as http://pmj.bmj.com/ it (1923), Ladd (I933) and Ladd and Gross (I94I), returns to the peritoneal cavity. padiatric surgeons have for many years recognized The first point to note is that it is only the rotational anomalies as a cause of intestinal midgut that rotates and this is emphasized in A obstruction, but general surgeons seem to be less and C which show how the ring, middle and index familiar with it in adults. Findlay and Humphreys fingers press the same bit of pipe cleaner on to the (1956) and Louw (I960) have drawn attention to same bit of table-top throughout so that the the occurrence of the condition in adults. beginning of the 'midgut', the beginning of the This paper reports two adult patients with 'superior mesenteric artery' and the end of the on September 25, 2021 by guest. chronic duodenal ileus who were operated on in a 'midgut' remain fixed during the manipulations, phase of acute duodenal obstruction; both of them as indeed they do in the embryo. The pre- and had suffered from 'digestive upsets' for many post-arterial mesenteries have been hatched-in in years (26 and I4 respectively) and both were cured the diagrams but they have to be imagined in the by placing the bowel in the position of non-rotation. model. 'B' illustrates how the midgut loop rotates Unless a surgeon is familiar with the anomalies anti-clockwise through three right angles from its of rotation that may occur and their treatment he is initial position in the sagittal plane. liable to be perplexed when suddenly confronted 'C' illustrates how the duodenum comes to lie on the operating table with a case of malrotation. behind the superior mesenteric artery and how it *Present address: St. James's Hospital, Balham, acquires a further covering of peritoneum, namely London, S.W.I2. that of part of the post-arterial mesentery. Nor- September I963 ROXBURGH: Duodenal Ileus and Intestinal Malrotation 535 Postgrad Med J: first published as 10.1136/pgmj.39.455.534 on 1 September 1963. Downloaded from IIJUNUM. I * l W 1iF : -vf: * l RIGHT HALF O. DUODENUM -4----- i, Protected by copyright. FIG. i.-See text. -CAEC VI -:-0s11:%L TERMINAL ILEUM PLECNIC FLEXG* mally most of this post-arterial mesentery gets 'plastered down' against the posterior abdominal wall (and fuses with the peritoneum already there) sumtofr ~FLEZM right up to the line of the superior mesenteric PrPnf rtm:l The re- artery. pre-arterial mesentery, however, StLL .I.W'A- mains hanging free as the mesentery of the small bowel rather like the fly-leaf of a book. The long Mwswnttry-- oblique attachment of the root of the mesentery across the posterior abdominal wall is thus ex- plained. Fig. C also illustrates how, at the end of transverse and descending colon are on the the second stage of rotation, the cmcum is sub- left side of the abdomen. The condition is hepatic in position. The downward growth of the rare. http://pmj.bmj.com/ c'cum and the various fixations already mentioned (b) Partial failure of rotation: sometimes only constitute the third stage of intestinal rotation. the post-arterial loop rotates but cannot do so completely because the pre-arterial loop Abnormal Intestinal Rotation has failed to do so; the latter thus blocks the A number of faults can occur during the process further progress of the former. On other of rotation: occasions the pre-arterial loop rotates re- of the artery but comes to a (i) The gut may never extrude at all; this occurs versely in front on September 25, 2021 by guest. in extroversion of the cloaca. halt when it meets the post-arterial loop (ii) If it does extrude it may fail to return; the coming round in front of the artery from the child is then born with an exomphalos. other side. (iii) If it does return it may in so doing fail in The third stage of rotation is a misnomer a greater or lesser degree to rotate. because by the time it is reached all rotation (a) Complete failure of rotation results in non- should have been accomplished. The third rotation wherein the duodenum runs straight stage really consists of various peritoneal down the right paracolic gutter to a small fusions whereby the bowel is anchored in its bowel that lies in the right iliac fossa. The proper position. If rotation has been im- small bowel ends by entering the large bowel perfect then fixation will be abnormal (i.e. from the right side. The ascending colon deficient or misplaced) and even when the lies more or less in the midline and the bowel rotates properly fixation may yet be El 536 POSTGRADUATE MEDICAL JOURNAL September i 963Postgrad Med J: first published as 10.1136/pgmj.39.455.534 on 1 September 1963. Downloaded from abnormal. When fixation is deficient, vol- vulus is possible, and when it is misplaced obstruction is possible. It is most im- portant to appreciate that both volvulus and obstruction by abnormally placed bands frequently occur in the same patient and in every case both causes must be looked for. The exact details of these errors of rotation and fixation are very variable and examples of this type are grouped together under the term malrotation. (iv) As the gut returns it may rotate clockwise instead of anticlockwise and the discovery of a transverse colon running behind the superior mesenteric vessels and duodenum stigmatize the anomaly as reversed rotation. The condition is very rare. Case Reports Case I On March 5, I96I, a 29-year-old Cypriot was ad- mitted to the Central Middlesex Hospital as an emer- gency complaining of colicky upper abdominal pain and vomiting of three days duration and of painful spasms of his hands of some eight hours duration. He had himself noticed visible gastric peristalsis. The Protected by copyright. pain was eased by vomiting and also if he lay semi- recumbent on his left side. The vomit contained food that he had eaten several days previously. He said FIG. 2a.-Case i: Barium meal at first admission. that he had suffered from attacks of abdominal pain and vomiting for as long as he could remember and had been told by his father that he had had them ever since he was 3 years old. When he was 9 years old he was investigated in Cyprus and although the radio- logist reported some abnormality of the bowel his own doctor discounted this as the cause of his symptoms and, attributing the attacks to subacute appendicitis, removed his appendix. The operation was done through a right lower paramedian incision and it took an unusually long time, doubtless due to the appendix being in the left iliac fossa. He derived no benefit from the appendicectomy and at the age of Izhe had his first attack of gastric tetany.
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