Findings: The third portion of the duodenum lies anterior to the superior mesenteric vessels.

There is also
transposition of the superior mesenteric vessels with the artery located to the right of the superior
mesenteric vein. Following the small bowel distally, the majority of the small bowel is located within the right
half of the abdomen while the colon is located predominantly in the left abdomen. The cecum and appendix
are present within the left upper quadrant the abdomen without evidence of adjacent inflammation. .

Diagnosis: Intestinal malrotation in an adult female.

Intestinal malrotation often presents during the neonatal period. Normal embryological bowel rotation results
in the ligament of Treitz being located to the left of the spinal cord at the level of the duodenal bulb with the
distal portion of the mesentery located within the right lower quadrant of the abdomen. In cases of
malrotation, there is incomplete 270 degree counterclockwise embryological rotation of the bowel about the
omphalomesenteric vessels resulting in an anatomic pattern ranging from non-rotation of the small bowel
and colon (as was the case here) to partial rotation.

Findings often associated with diagnosis in the neonatal period may include gastroschisis, omphalocele,
diaphragmatic hernia and duodenal or jejunal atresia. In adults and adolescents, internal hernias secondary
to the presence of fibrous peritoneal bands (Ladd bands) may be present. Recurrent episodes of colicky
abdominal pain, vomiting, diarrhea and malabsorption from chronic venous and lymphatic obstruction may
also occur. In all cases, there is an increased risk of midgut volvulus resulting from clockwise twisting of the
bowel around the SMA axis secondary to the narrowed mesenteric attachment. This is potentially life
threatening and requires emergent correctional surgery.

Key radiologic features:

CT: SMA to the right of the SMV, spiraling of duodenum and jejunum around the SMA axis, gastric
outlet obstruction.
Ultrasound: reversal of SMA and SMV, distention of the proximal duodenum.
Upper GI: Abnormal position of the duodenojejunal junction, spiraling of small bowel (corkscrew
appearance).

Key points:

Malrotation is most often diagnosed in the neonatal period.

The clinical presentation in older patients (adolescents and adults) is often non-specific.

References:

1. Donnely, Lane F., MD. Fundamentals of Pediatric Radiology. W B Saunders, 2001.

2. Pickhardt PJ, Bhalla S. Intestinal malrotation in adolescents and adults: spectrum of clinical and
imaging features. AJR Am J Roentgenol. 2002 Dec;179(6):1429-35.