What is malrotation?
Malrotation means your child’s intestines are not in the normal position.
When babies are developing, their intestines begin as a short straight tube. During the first few months of pregnancy, the intestines start to grow longer. As they grow, they turn inside the belly (abdomen). When they reach the right position, they attach to the back of the abdomen. This holds them in place.
In babies with malrotation, the intestines don’t turn and attach in the normal way.
Malrotation in Children
About 1 in 500 babies born in the United States has malrotation. It may not cause any health problems. But sometimes it leads to serious problems, such as:
- Ladd’s bands – These are bands of tissue that may attach the first part of the small intestine (duodenum) to the first part of the large intestine (colon). This can block the duodenum and keep food from passing through.
- Volvulus – In this condition, the intestines twist sharply. The twist can squeeze the blood vessel that carries all of the blood to the intestines. If blood flow is cut off, the intestines can be damaged and the tissue can die.
Both of these problems can be life threatening.
Most children who have had problems from malrotation do well and grow normally if the problems are found and treated early and there’s no lasting damage to their intestine.
Some children with other conditions may be more likely to have malrotation. These include some heart conditions, heterotaxia (where other organs are not in the normal place) and other problems, such as being born with more than one spleen or none at all.
Malrotation at Seattle Children’s
We have treated many babies, as well as older children, with malrotation at Seattle Children’s. Our surgeons are experienced at doing the surgeries these children need to move and attach their intestines and to correct volvulus.
The experts you need are here
When you come to Seattle Children’s, you have a team of people to care for your child. Along with your child’s surgeon, you are connected with gastroenterologists, nurses, dietitians, child life specialists and others. We work together to meet all of your child’s health needs and help your family through this experience.
Since 1907, Seattle Children’s has been treating children only. Our team members are trained in their fields and also in meeting the unique needs of children. For example, the doctors who give your child anesthesia are board certified in pediatric anesthesiology. This means they have extra years of training in how to take care of kids. Our child life specialists know how to help children understand their illnesses and treatments in ways that make sense for their age.
Symptoms of Malrotation
Most children with malrotation have symptoms before they are 1 year old. Some children don’t have symptoms until they are older, and some never have symptoms. Some people live with malrotation their whole life and never know they have it.
Symptoms happen if the intestine gets blocked (such as by Ladd’s bands or volvulus) or if blood flow to the intestines is cut off.
The most common symptom is green or yellow vomit (also called bilious because it contains bile, a liquid made in the liver to help digest fats).
Babies or children with malrotation or volvulus may also have these symptoms:
- Fussiness or crying, and nothing seems to help
- Tiredness, sluggishness or no energy (lethargy)
- Problems with stools (feces), such as no stools, irregular stools, diarrhea or bloody stools
- Swollen belly that’s tender when touched
- Fast heart rate and breathing
- Looking sick
Children with malrotation who have no symptoms may never have their condition diagnosed. It may be found by accident when they have an X-ray or surgery for some other reason, maybe not until they are adults.
If your child has symptoms, your child’s doctor will ask for a detailed history of your child’s illness. The doctor will do a thorough exam.
To see your child’s intestines, the doctor may take X-rays, including an upper GI (PDF) (gastrointestinal) series and a lower GI (PDF) series (barium enema). These can show where the intestines are and if they are blocked.
First your child will have a liquid that shows up on X-ray film. This may be put through a tube that passes through your baby’s nose to their stomach (nasogastric tube, or NG tube) or through a tube placed in your baby’s rectum (enema). Older children may be able to drink the liquid. An upper GI is the most accurate way to make the diagnosis.
Children with symptoms caused by malrotation need surgery to move their intestines. If they have volvulus, they need surgery right away. Volvulus is a life-threatening emergency. If they do not have volvulus, they may not need surgery right away. But surgery is important to clear any blockage and to reduce the chance for volvulus.
Even if your child has had no symptoms of malrotation, talk with a surgeon about whether your child should have surgery to correct it. Nearly all children need surgery to prevent serious problems later. A surgeon can explain the risks and benefits and help you decide what’s best for your child.
Before surgery, your child will need a nasogastric (NG) tube, which goes through their nose to their stomach, to empty their stomach.
They will also need intravenous (IV) fluids to prevent dehydration, to give them nutrients and to give them antibiotics to prevent infection. This will be part of your child’s care before, during and after surgery.
At the time of surgery, we give your child medicine to make them sleep without pain (general anesthesia).
The surgeon makes a small cut (incision) above the belly button and brings the intestines out through this opening. The surgeon untwists the intestines and cuts the Ladd’s bands (bands of tissue that attach the first part of the small intestine to the first part of the large intestine).
During the surgery, the surgeon checks the health of the intestines. The surgeon looks for a pink color in the tissue, which shows that blood flow is good. If the tissue looks healthy, the surgeon folds the small intestine into the right side of the belly (abdomen) and the large intestine (colon) into the left side of the belly. The intestines are placed so they are not likely to twist in the future.
The new placement of the intestines is not the same as the normal placement. This means your child’s appendix (a small organ attached to the colon) is not in the usual place. If your child ever got appendicitis, it might be hard to diagnose. So your surgeon takes out your child’s appendix during the surgery for malrotation. (The appendix has no clear function, and people live normally without it.) Then the incision is closed.
If it’s not clear that the intestine has good blood flow, your child may need another surgery within 24 to 48 hours to recheck the intestine. If a segment of intestine does not look healthy, the surgeon may remove that segment.
Part of the intestine may be damaged or the tissue may die if it isn’t getting good blood flow. If a segment of your child’s intestine is damaged, the surgeon will remove that segment. The goal is to keep as much healthy intestine as possible.
Surgeons cut on each side of the damaged segment and take it out. If the rest of the intestine looks healthy, they sew the 2 ends of the intestine together (primary anastomosis, pronounced an-as-toe-MOE-sis).
If it does not look healthy, they may make an ostomy (pronounced OST-uh-mee). They make 2 small openings (stoma) in your child’s belly. Each open end of the intestine is then sewn to one of the openings. One of these lets waste come out of the body into a plastic pouch attached on the outside. The other opening is used to clean the lower intestines. If your child needs this procedure, you will get instructions about how to care for the stoma.
In most cases, an ostomy is temporary. Later, when the intestine is healthier, the surgeon does another surgery to attach the ends of the intestine and close the stoma. Usually this is about 8 weeks later. If a child had to have a large segment of intestine removed, the ostomy might be permanent. This is not common. If your child needs a large segment of intestine removed, they may be at risk for short bowel syndrome. The surgeon will keep as much intestine as possible to try to prevent this.
After surgery, your child will be in the recovery room for about an hour and then go to a room in the hospital. Some children who are quite ill stay in our intensive care unit (ICU) or neonatal ICU (NICU), where they get the high level of care they need. When they’re ready, they move to a regular hospital room and eventually to home.
The length of hospital stay for children with malrotation is usually about a week. This depends on factors like how quickly the intestine recovers from surgery and how soon the child can start eating again.
Right after surgery, your child will get all their nutrition through an IV line. They need this because their intestine goes to sleep, in a sense, after surgery. It takes a few days for the intestine to work again. After the child starts passing gas, the doctors will know the intestine is working again and feedings may be started. Some babies may have to get feedings through a tube that goes through the nose or mouth into the stomach (nasogastric tube, NG tube; or orogastric tube, OG tube).
We will give your child pain medicine to make them comfortable.
The surgeon will stay closely involved in your child’s care while they are in the hospital. When your child goes home, the surgeon will schedule a follow-up visit 2 to 3 weeks after the surgery to make sure the incision is healing.