Congenital intestinal malrotation

　　1. The midgut has not rotated

　　The midgut did not rotate during its return to the abdominal cavity, maintaining its original position. Both the small intestine and the colon hang from a common mesentery, with the root of the mesentery arranged in a sagittal plane in front of the spine, often accompanied by umbilical hernia and abdominal wall defects.

　　Second, incomplete intestinal rotation

　　After the intestinal loop rotates 90°, it stops, the small intestine hangs on the right side of the abdominal cavity, the cecum and proximal colon are located on the left side of the abdominal cavity, the appendix is located in the lower left abdomen, which is a common rotation anomaly. The lower part of the duodenum does not cross the superior mesenteric artery, but is located on the right side of the root of the mesentery, there is no duodenojejunal loop, and the terminal ileum enters the cecum from the right to the left. The ascending colon is in front of or on the left side of the spine, and the duodenum, small intestine, and colon hang from the common free mesentery. The development of the colon itself makes the transverse colon horizontal, the liver flexure of the proximal colon extends to the right at an acute angle, and the duodenum is intertwined with the proximal colon.

　　Third, type I intestinal rotation anomaly

　　After the intestinal loop rotates 180°, it stops, the lower part of the duodenum is behind the root of the mesentery, the cecum and ascending colon are located on the midline of the abdomen, and there are strip-like peritoneal adhesions or bands, crossing in front of the second part of the duodenum, attaching to the right posterior abdominal wall. When the proximal colon stops developing, the cecum is on the right side of the spine in front of the duodenum, compressing the duodenum.

　　Fourth, type II intestinal rotation anomaly

　　Reversal rotation or mixed rotation.

　　1. After the midgut rotates counterclockwise by 90°, it then rotates clockwise by 90° to 180°, placing the descending part of the duodenum in front of the superior mesenteric artery.

　　2. The proximal colon migrates to the right, and is completely or partially located in front of the duodenum and mesentery.

　　3. When the proximal colon and its mesentery shift to the right, the small intestine and mesenteric blood vessels are all wrapped in the colon mesentery, forming a colon mesentery hernia. The mesentery of the ascending colon forms the hernia sac wall, and the small intestine inside the sac may become obstructed.

　　4. After the midgut rotates counterclockwise by 180°, the transverse colon runs behind the peritoneum, the small intestine and ascending colon are in normal position, the transverse colon crosses behind it, the lower part of the duodenum is in front, and if the midgut continues to rotate counterclockwise by 180°, it will form an intestinal torsion with the root of the mesentery as the axis, the cecum moves to the left, and the duodenum is located on the right.

　　Fifth, total mesentery

　　The mesentery of the ascending colon is not attached to the posterior abdominal wall, which is a combined abnormality of malrotation of the midgut. It can also be a single abnormality of normal intestinal rotation. At this time, the lower part of the duodenum is located behind the superior mesenteric artery, and the duodenal loop is located on the left side of the abdomen. When the total mesentery is formed, the root of the mesentery forms a thin stalk, extending fan-shaped from below the pancreas, and the ascending colon is close to the right abdominal wall but without adhesion. If the mesentery of the ascending colon is partially adhered to the posterior abdominal wall, the cecum and adjacent ascending colon are free.

　　Combined malformations: accounting for 30% to 62%. Half of them are duodenal atresia, others include ileal atresia, congenital megacolon, mesenteric cysts, etc.

　　Approximately 20% of cases are accompanied by hyperbilirubinemia, the cause of which is unclear. It may be due to the expansion of the stomach and duodenum, which compresses the common bile duct. It may also be due to the compression of the portal vein and mesenteric vein, reducing blood flow, and compensatory increase in blood flow of the hepatic artery, causing untreated indirect bilirubin to return to the circulation. At the same time, due to the decrease in portal vein blood flow, liver cell hypoxia affects the formation of the enzyme system.

　　For newborns with symptoms of high-positioned intestinal obstruction, such as vomiting containing a large amount of bile, and those who have had normal meconium excretion, the diagnosis of intestinal rotation abnormality should be considered. X-ray examination can be used to confirm it. The abdominal plain film can show the enlargement of the stomach and duodenum, with a liquid level, while the small intestine has only a small amount of gas filling. Barium enema is the main diagnostic basis. The position of the cecum can be confirmed as located in the upper abdomen or the left abdomen. However, if the cecum is free or the barium fills the intestinal lumen, the position of the cecum may be downwardly displaced, so even if the position of the cecum is normal, it cannot exclude the possibility of intestinal rotation abnormality. When it is difficult to differentiate between intestinal malrotation, duodenal atresia or stenosis, and annular pancreas, all showing high-positioned intestinal obstruction, and it is difficult to differentiate, it is not advisable to perform too many examinations, and early surgical exploration should be performed.

　　The follow-up results prove that the surgical efficacy is good, although the mesentery of the small intestine is still free, theoretically there is a possibility of recurrence of intestinal torsion, but clinical experience has shown that recurrence is rare. However, there may be intermittent abdominal pain, persistent digestive and absorptive disorders, leading to anemia and low plasma protein levels. The degree of malabsorption after resection of necrotic intestinal tract depends on the length and function of the remaining intestinal tract. The death cases mostly have other malformations.

　　1. Plain film

　　Gastric and duodenal air expansion, with a liquid level showing a 'double bubble sign', and less air in the small intestine; when accompanied by intestinal torsion, the signs of high-positioned intestinal obstruction are particularly obvious, and abdominal effusion may occur.

　　2. Contrast examination

　　Gastric dilation, obstruction of the second and third segments of the duodenum, the obstructed end呈cone-shaped or knife-cut; the duodenojejunal flexure is located abnormally; the proximal jejunum or the entire jejunum is located in the upper right abdomen, such as the entire right abdomen, can be diagnosed as intestinal malrotation. When combined with intestinal torsion, the distal duodenum and the proximal jejunum spiral down in a

　　3. Barium enema

　　The cecum is displaced inward, ascending, and the transverse colon is twisted in the left abdomen and upper abdomen. The cecum is free and located in the upper right abdomen, upper abdomen, or left abdomen.

　　The diet for patients with congenital intestinal rotation abnormality should first be easy to digest, starting with foods like millet porridge, and avoiding cold, hard, and other foods that produce gas. Various foods that produce gas should be consumed under the doctor's advice.

　　1. It is recommended to consume light and nutritious, fluid foods, such as congee, vegetable soup, lotus root starch, egg flower soup, and noodles, etc.;

　　2. Foods that are easy to digest and promote defecation, such as vegetables: kelp, pork blood, carrots, etc., and fruits: hawthorn, pineapple, papaya, etc.; eating foods rich in fiber, such as various vegetables, fruits, brown rice, whole grains, and beans, can help defecate, prevent constipation, stabilize blood sugar, and reduce blood cholesterol levels;

　　3. It is recommended to consume foods rich in protein and iron, such as lean meat, fish and shrimp, animal blood, animal liver and kidney, egg yolk, soy products, as well as jujube, green leafy vegetables, sesame paste, and so on;

　　4、宜吃加工或烹饪精细的食物，以利咀嚼及消化。全蛋每周可吃1—2个。奶类及其制品、五谷根茎类、肉鱼豆蛋类、蔬菜类、水果类及油脂类等六大类食物，宜多样摄取，才能充分的获得各种营养素。

　　The conventional method of Western medicine for treating congenital intestinal rotation anomalies

　　1. Those without symptoms should not undergo surgery and should be observed. Obstruction symptoms or acute abdominal pain attacks are indications for early surgical treatment. The presence of intestinal bleeding or signs of peritonitis suggests torsion and requires emergency treatment.

　　2. The position of the intestinal tract is normal, but when there is a general mesentery, the cecum should be fixed to the right lateral parietal peritoneum from the ileocecal junction to the duodenojejunal flexure. To prevent abnormal movement of the structure, so that the small intestine does not get stuck between the mesentery of the colon and the posterior parietal peritoneum, the mesentery of the ascending colon can be diagonally fixed to the dorsal parietal peritoneum from the ileocecal junction to the duodenojejunal flexure.

　　3. In cases of intestinal rotation anomalies Type I and II, the membranous bands and adhesions should be released, the duodenum should be fully dissected, the cecum should be freed, and the twisted intestinal tract should be corrected, so that the duodenum runs downward along the right side of the abdominal straight, the small intestine is placed on the right side of the abdomen, and the cecum and colon are placed on the left side of the abdominal cavity (Ladd procedure). The appendix should be routinely removed to avoid misdiagnosis in the future.

　　4. When the transverse colon is located posteriorly, it is often due to reverse rotation. The repair requires the twisted intestinal tract to be rotated counterclockwise by 360° to bring the retroperitoneal transverse colon to the front of the mesenteric root, and to fix the cecum and ascending colon to the right parietal peritoneum, moving the lower part of the duodenum in front of the mesenteric vessels to the right side of the abdomen to prevent compression, relieve the stasis of the mesenteric veins caused by reverse rotation, and restore the通畅.