Case 11328

Asymptomatic intestinal non-

rotation in an adult
Published on 27.11.2013

DOI: 10.1594/EURORAD/CASE.11328
ISSN: 1563-4086
Section: Abdominal imaging
Area of Interest: Abdomen
Procedure: Contrast agent-intravenous
Imaging Technique: CT
Special Focus: Congenital Case Type: Clinical Cases
Authors: Chassagnon G, Bleuzen A, Cottier JP
Patient: 61 years, female

Clinical History:

A healthy woman was referred for CT evaluation of kidney stones. She was asymptomatic and had an unremarkable
past medical history except for kidney stones.
Imaging Findings:

Contrast-enhanced computed tomography (CT) of the abdomen was performed in the portal venous phase. In
addition to bilateral kidney stones and left pyelitis, an abnormal localization of the bowel was observed. The
duodenum, duodeno-jejunal junction (DJJ) and rest of the small intestine were situated to the right of midline while
the caecum and colon were left-sided. The orientation of the superior mesenteric vessels was inverted, the superior
mesenteric artery (SMA) being located to the right of the superior mesenteric vein (SMV). Except for
underdevelopment of the uncinate process of the pancreas, no other abnormalities were observed.
Discussion:

Intestinal malrotation occurs in approximately 1 in 500 live births [1]. Although it is usually diagnosed during
childhood, asymptomatic forms of malrotation may go undetected.

Intestinal malrotation includes several congenital positional anomalies of the small intestine of which non-rotation
and incomplete rotation are the most frequent forms [2]. It results from early failure of the normal 270°
counterclockwise rotation occurring between 5th and 12th gestational weeks while the midgut growths [3]. The first
intestinal rotation occurs at 6 weeks when the duodenum rotates 180° to lie to the right of the SMA and the colon
rotates 90° to lie on the left of the SMA [3-4]. Cessation of intestinal rotation at this stage corresponds to intestinal
non-rotation with small intestine (and DJJ) remaining on the right of the midline while the colon remains on the left.
At 10 weeks, the duodenum completes its final 90° rotation and becomes left-sided while the colon rotates 180° until
the caecum resides in the right lower quadrant [3-4]. Any arrest of intestinal rotation during this stage is termed
incomplete rotation. As stages of rotation differ for the small versus the large bowel, incomplete rotation includes a
spectrum of partial rotational anomalies [2, 4].

In the adult, non-rotation is usually asymptomatic but patients may offer a history of intermittent nonspecific
symptoms such as abdominal pain [2].

The principal sign of intestinal non-rotation on CT is a left-sided caecum associated to right-sided DJJ and small
intestine. Analysis of the position of superior mesenteric vessels is useful as it had been reported that almost all
patients have an abnormal relationship of these vessels, with the SMA located anterior to or to the right of the SMV
[5]. Most patients have normal position of the atria and the other viscera (situs solitus) but some may present with
situs inversus or situs ambiguus [5]. A variety of other abnormalities such as underdevelopment or absence of the
uncinate process of the pancreas, left-sided or interrupted inferior vena cava and azygos or hemiazygos
continuation may be associated with intestinal malrotation [2, 5].

The most important complication of non-rotation is midgut volvulus by clockwise twisting of the bowel around the
SMA [2]. The risk of midgut volvulus is lower in non-rotation than in incomplete rotation [2, 4] but according to some
authors it justifies preventive surgical correction by Ladds’ procedure for all operative candidates regardless of age
[2, 4, 6]. Whether asymptomatic require surgery remains controversial [6].
Differential Diagnosis List: Asymptomatic intestinal non-rotation in an adult., Incomplete intestinal rotation,
Reversed intestinal rotation

Final Diagnosis: Asymptomatic intestinal non-rotation in an adult.

References:

Stewart DR, Colodny AL, Daggett WC (1976) Malrotation of the bowel in infants and children: a 15 year review.
Surgery 79:716-20 (PMID: 1273757)
Pickhardt PJ, Bhalla S (2002) Intestinal malrotation in adolescents and adults: spectrum of clinical and imaging
features. AJR Am J Roentgenol 179:1429-35 (PMID: 12438031)
Strouse PJ (2004) Disorders of intestinal rotation and fixation. Pediatr Radiol 34:837-51 (PMID: 15378215)
Applegate KE, Anderson JM, Klatte EC (2006) Intestinal malrotation in children: a problem-solving approach to the
upper gastrointestinal series. Radiographics 26:1485-500 (PMID: 16973777)
Zissin R, Rathaus V, Oscadchy A, Kots E, Gayer G, Shapiro-Feinberg M (1999) Intestinal malrotation as an
incidental finding on CT in adults. Abdom Imaging 24:550-5 (PMID: 10525804)
Fu T, Tong WD, He YJ, Wen YY, Luo DL, Liu BH (2007) Surgical management of intestinal malrotation in adults.
World J Surg 31:1797-803 (PMID: 17457643)
Figure 1
a

Description: Small intestine is right-sided while descending colon is located in the midline (arrowhead).
Mesenteric vessels are inverted with SMA (arrow) situated to the right of the SMV. Left kidney stone
and left pyelitis are seen. Origin: Tours University Hospitals, Tours, France
Figure 2
a

Description: Axial CT image at the level of the ileocecal valve (arrowhead) shows the caecum located
in the midline. Origin: Tours University Hospitals, Tours, France
Figure 3
a

Description: Coronal CT images reveal an abnormal position of the duodenum with right-sided
duodeno-jejunal junction (arrow) Origin: Tours University Hospitals, Tours, France
Figure 4
a

Description: The colon is left-sided while the small intestine is situated to the right of midline.Origin:
Tours University Hospitals, Tours, France
Figure 5
a

Description: The uncinate process of the pancreas is underdeveloped (arrowhead) and the spleen is
within normal limits, without polysplenia. Origin: Tours University Hospitals, Tours, France