Alan Price, E

Kane, Gerald

English

AJOL - African Journals Online

9 Julie 1955 S.A. TYDSKRIF VIR GENEE£KUNDENON-ROTATION OF GUTWITH REPORT OF CASE OF LEFT-SIDED APPENDICEAL ABSCESSE. ALAN PRICE, M.B., B.CH. (RAND), D.M.R.D., R.C.P. & S. (E G.)X-Ray Department, J~hannesburg General H~spitalANDGERALD IUNE, M.B., B.CH. (RA ID), F.R.C.S. (E 'G.)Johannesburg General Hospital655The surgical importance of anomalies of intestinalrotation and the diagnostic difficulties related to theirpre-operative recognition has prompted the study ofthis case.The term 'non-rotation of gut' is synonymouswith 'mesenterium commune' and with 'left-sided colon'a term used by earlier workers.9 Some Americanwriters 6, 11 group all anomalies of intestinal rotationand mesenteric fixation under the one term of 'mal-rotation'. We prefer, however, to use Dott's classifica-tion.4 The term 'non-rotation of gut', according to thisclassification, refers to a complete failure of rotationof the mid-gut segment. This condition is not to beconfused with 'situs inversus', where there is usuallycomplete transposition of all the thoracic and abdominalviscera.It is not the purpose of this paper to discuss in detailthe embryology of intestinal rotation. The widelyaccepted work of Frazer and Robbins,5 and Dott,4gives comprehensive accounts of the factors concernedand the mechanism.The errors of development are commonest in theInid-gut, which extends from the duodenal biliarypapilla to the left third of the transverse colon, and isthat portion of the gut which is supplied by the superiormesenteric artery. During the first 4-5 weeks of intra-uterine life the Inid-gut herniates through the umbilicuswith the cord, carrying with it the superior mesentericartery. Both the pre-arterial and post-arterial segmentsof the mid-gut are situated in the sagittal plane at thatstage. Three stages are recognized in the rotation andreturn of the gut. The 1st stage takes place betweenthe 4th and 10th weeks of intra-uterine "life, while theloop lies in the umbilical cord. During this stage thepre-arterial segment rotates -from the sagittal plane tothe right in an anti-clockwise direction through 900around the axis of the superior mesenteric vessels.As a result, the pre-arterial segment, which later formsmainly the small bowel, lies on the right side, and thepost-arterial segment~ which will form mainly the largebowel, lies on the left. Failure of the 1st stage of rota-tion, which is rare, occurs in the condition of exom-phalos. The 2nd stage is the stage of return and occursbetween the 10th and 11th week. It consists of a reduc-tion of the umbilical hernia with the return of thejejunum, ileum, caecum and colon, in that order,behind the superior mesenteric vessels into the ab-dominal cavity. This results in a further 1800 of anti-clockwise rotation. This stage comes to an end whenthe whole length of the colon is in its proper placeFig. lA. Ventral view at end of 2nd stage of rotation. Themid-gut loop has undergone an anti-clockwise rotation of270°. A-B is mid-gut segment. I = Aorta. 2=Post-arterialmesentery. 3=Pre-arterial mesentery.Fig. lB. Diagram illustrating 'non-rotation' of mid-gut loop.The normal anti-clockwise rotation has been arrested at 90°,and the embryonic position existing at the 8th week is carriedforward unchanged into adult life. I = Aorta. 2=Superiormesenteric artery. 3=Inferior mesenteric artery. 4=Site ofthe vitelline duct and artery.relative to the small bowel; i.e., small bowel on the leftside and the caecum on the right side in the sub-hepaticregion (Fig. la). It will be seen that the Inid-gut loophas now rotated on the axis of the superior mesentricvessels through 2700 from its original sagittal plane.The term 'non-rotation' refers to a failure in the2nd stage. The returning bowel fails to undergo theusual extra 1800 of anti-clockwise rotation and thusretains the same primitive relationships as during the6th week of intra-uterine life, viz. the smaU bowel onthe right side and the colon and caecum on the leftside (Fig. Ib). This is the commonest variation metwith in radiological practice. lOIn those cases where the 2nd stage of rotation isincomplete a distribution of the gut intermediate be-tween the normal and non-rotation results. This isknown as 'malrotation'.Other rarer anomalies of rotation which may occurduring the second stage are:656 S.A. MEDICAL JOURNAL 9 July 1955(a) Reversed Rotation. This consists in a clockwiserotation of the mid-gut loop. The post-arterial segmentpasses behind the artery and thus the transverse coloncomes to lie behind the duodenum. The viscera other-wise attain normal positions except for the anteriorand posterior relationship, which is reversed.(b) Paraduodenal Hernia. According to Andrews,lduring the 2nd stage of rotation the caecum and colon,as a result of an anomalous 90° clockwise rotation,envelop the small bowel in either the mesentery of theascending colon '(right paraduodenal hernia) or themesentery of the transverse colon (left paraduodenalhernia).(c) Undescended Caecum. This, however, may becongenital or due to adhesions.The 3rd stage is concerned with the fixation of partsof the mid-gut mesentery to the posterior peritoneum.The normal fixation of the duodenum, caecum andascending colon to the posterior abdominal wall, andthe formation of the extended mesenteric root, takesplace then.The majority of cases of non-rotation are discoveredaccidentally and give rise to no symptoms. Patientswith such anomalies, however, may present with symp-toms and signs of intestinal obstruction or strangula-tion, or may complain of vague gastro-intestinal symp-toms usually diagnosed as of a functional nature,while a small proportion may present a picture sug-gesting coeliac disease.6 In such cases knowledge ofthe presence of an intestinal positional anomaly is ofconsiderable importance, because the clinical picture,the diagnosis and the subsequent therapy may be greatlyinfluenced by it. In the 48 cases collected by Dott4 theerroneous fixation of the bowel was the directly 'pre-disposing cause of intestinal obstruction in 27 % of thecases. The precipitating factor was either torsion orvolvulus. The 2 main conditions which are apt to beoverlooked and misdiagnosed in patients with thisanomaly are (1) the various types of intestinal ob-struction associated with non-rotation, particularlyvolvulus neonatorum in which there is a clockwisevolvulus of the mid-gut from duodenum to transversecolon around the duodeno-colic isthmus; and (2) anabnormally situated appendix becoming diseased or,in other words, a left-sided appendicitis. A case of thelatter condition is now presented.CASE REPORTH.M.G., a 52-year-old female, was admitted to hospital in 1948complaining of abdominal pain and vomiting of 3 weeks' duration.Three weeks before admission she started vomiting in the middleof the night and experienced severe cramp-like pain all over theabdomen. This attack continued for 12 hours. She then stoppedvomiting but felt a dull pain in her 'left groin' and for the rest oftbe 3 weeks-she had frequent attacks of sharp pain and vomiting.Tbe attacks followed after meals and started with a 'swelling'coming up on tbe left side of the abdomen. Since the onset thepatient had bad diarrhoea, but before this illness she bad beenconstipated. Two days before admission a doctor told her thatshe had a temperature of 102 ·2°F. There was nothing significantin her past history except tbat she had had an uncomplicatedcholecystectomy 2 years earlier.At examination inlrnediately on admission her temperaturewas lOO ·:tF, the pulse 110 per minute and the respiratory rate28 per minute. Her tongue was dry and there was guarding andtenderness as well as an indefinite swelling on the left side of theabdomen and particularly in tbe left iliac fossa. A gynaecologicalexamination was negative. Otherwise no significant abnormalitieswere found.She was operated on under general anaesthesia 4 days later,via an oblique left lower abdominal incision. The large bowelwas found matted and a left-sided pelvic abscess was opened,which delivered a large quantity of foul-smelling pus, found on'culture to contain coliform bacilli. No obvious cause could befound for the pus formation. No foreign body was seen or feltand no diverticula were noted. Two drains were inserted and thewound closed. A transverse colostomy was then establishedthrough a supra-umbilical mid-line incision. There was no ap-parent difficulty in finding tbe segment of the transverse colonand no anomaly of the mesocolic attachment was recorded.The patient was put on penicillin and made good progress. Shewas discharged 4 weeks later with the colostomy acting well.The final diagnosis entered on the case sheet was diverticulitiswitb pelvic peritonitis.Six montbs later when the patient returned to hospital forclosure of the colostomy she developed a left-sided empyemabefore the operation was undertaken and therefore closure hadto be postponed. Recently she again presented herself for closureof the colostomy. She was then referred for X-ray examinationof the gastro"intestinal tract and the following were the findings:'The barium meal passed normally along the oesophagus intothe stomach, which was normally placed, presented no unusualfeatures, and emptied at a normal rate. There was deformityat the duodenal cap but no active ulceration was noted. The1st and 2nd parts of the duodenum took a normal course, thelatter passing vertically downwards a little to the right of themid-line. The direction of the lower flexure was reversed so thatthe 3rd part of the duodenum and the jejunum was situated inthe right hypochondrium (Fig. 2). On following the course of themeal through the gastro-intestinal tract, it was found that thewhole of the small intestine, with the exception of the last fragmentFig. 2. Case of 'non-rotation'. Supine post. ant. view showingthe jejunum situated completely to right of vertebral columnand the absence of the normal duodeno-jejunal flexure.9 Julie 1955 S.A. TYDSKRIF VIR GENEESKUNDE 657Fig. 3. Supine post. ant. view 3 hours later.Sketch ofFig. 3. 1. Jejunum. 2. Ileum. 3. llio-caecaljunctionshowing terminal ileum entering the caecum from right toleft. 4. Left-sided appendix overlying the sigmoid colon.5. Caecum. 6. Ascending colon. 7. Site ofcolostomy_ 8. Splenicflexure. 9. Descending colon. 10. Sigmoid colon. 'ote: Smallintestine is completely on the right, and large intestine onthe left.of the terminal ileum, lay on the right side of the abdomen. Therate _of passage of the meal through the small bowel was ratherrapid. Within an hour it was at the caecum and within 2 hourshad reached the colostomy. Films taken 3 hours after the ex-amination showed the terminal ileum entering the- caecum fromright to left instead of from left to right as is the case in the normal.The caecum and ascending colon were on the left side and thedescending colon rose rather high. The appendix was filled and,on screening, both the caecum and appendix wen; found to befixed and immobile, but no tenderness was elicited (Fig. 3). Sixhours after the administration of the meal, the barium was entirely •in the colon. No trace of diverticulosis or diverticulitis was noted,and the portion of the colon distal to the colostomy was perfectlypatent and functioned well. A barium enema which passed norm-ally confirmed the absence of diverticula or diverticulitis. Nostricture or irregularity of the lumen could be detected and therewas no disturbance of the motility or distensibility of the colon.Fluoroscopic examination of the thorax showed the heart andgreat vessels to be normally situated and the patient showed no ><radiological evidence of any other abnormality. The conclusionswere that the X-ray appearances were those of failure of the2nd stage of rotation of the mid-gut loop. The absence of anydiverticulitis, while the caecum and appendix were fixed andimmobile, suggested that the original pathological condition wasa left-sided appendiceal abscess'.It was suggested to the patient that an appendectomy wouldbe advisable but she refused operation. Extra-peritoneal closureof the colostomy was then performed.DISCUSSIO TThis case of left-sided appendiceal abscess presenteditself as one of diverticulitis with pelvic peritonitis.There was, however, no evidence of diverticulitis eithernidiologicaIly or at operation. The possibility of per-foration of the sigmoid colon by a foreign body suchas a fish bone is unlikely when one considers the onsetof symptoms, which started with central abdominalcolic, indicating obstruction to some part of the bowellumen. All the characteristic features of non-rotationof the gut were well demonstrated. According toBabaiantz and Kadruka2 the characteristic radiologicalfeatures of non-rotation are as follows:1. Right-sided inversion of the 3rd part of theduodenum.2. Absence of the duodeno-jejunal flexure.3. The small intestine is on the right side.4. Position of the proximal colon on the left side.5. Absence of the hepatic flexure.6. The terminal ileum enters the caecum from rightto left instead of from left to right.The value of pre-operative knowledge of the X-rayappearances or, if that is impossible, at least of post-operative roentgen studies is demonstrated by this case.The surgeon and radiologist should be aware of andkeep in mind the possibility of a left-sided appendix,and should know the radiological appearances of non-rotation of the gut, for otherwise the condition maybe passed over undetected. The diagnosis is almostimpossible without X-ray examination. This is notso in situs inversus, where the detection of a dextro-cardia and left-sided liver dullness will suggest left-sided appendicitis. The difficulty is further increasedby the fact that some appendicitis patients with thisanomaly are recorded as complaining of pain in theright iliac fossa although the appendix is on the leftside. According to Blegen,3 in a survey of 57 patientswho were operated- on for left-sided appendicitis,21 or 37 % had pain in the right iliac fossa. Evidence658 S.A. MEDICAL JOURNAL 9 July 1955suggests that in the left-sided appendix, although theviscera are transposed, the component parts of thenervous system are not reversed.,Those patients in whom. non-rotation is discoveredaccidentally on X-ray should be told of their anomalyand instructed to tell any doctor attending them in thefuture.This case also raises the question whether an ap-pendix which was previously diseased and associatedwith an abscess can fill on subsequent examination.Gramse et al.' found that, out of 32 patients who under-went appendiceal drainage and returned for intervalappendectomy, in 13 (40%) the removed appendixwas found to be healthy and normal on histologicalexamination. Hindmasch8 discussing the pathologyof appendicitis states, 'In many cases of appendicitisin which occlusion of the lumen was present, it wasnoted that the'infective process tended to stop at thepoint of obstruction. Only the distal portion wasinvolved by the diseased process'. It would thereforeappear that the proximal portion may remain unaffectedby the disease and, after subsequent fibrosis of theperforated end, remain viable and the lumen patent.SUMMARY1. The embryology and mechanism of non-rotationof the gut are briefly described.2. The pathological complications which may arisefrom this anomaly are mentioned.3. Left-sided appendicitis and the diagnostic diffi-culties encountered as a result of this uncommonsituation are discussed.4. A case of left-sided appendiceal abscess diagnosedas ruptured diverticulitis and pelvic peritonitis is re-ported.5. The characteristic radiological features of non-rotation of the gut are described.6. The changes which may take place in an appendixafter drainage of appendiceal abscess are referred to.It would appear that a large percentage may resume ahealthy viable state.We wish to acknowledge our thanks to Dr. Josse Kaye, ChiefRadiologist, Johannesburg General Hospital, Mr. M. K. Tuckerand Dr. Kenneth F. Mills (Superintendent, Johannesburg GeneralHospital) for their support and permission to publish this case.REFERENCES1. Andrews, E. (1923): Surg. Gynec. Obstet., 37, 740.2. Babaiantz, L. and Kadruka, S. (1932): J. Radiol. Electro!',16,251, quoted by Rubin, E. L. (1935): Lancet, 2, 1222.3. Blegen, H. M. (1949): Ann. Surg., 129,244.,4. Dott, N. M. (1922): Brit. J. Surg., 11,251.5. Frazer, J. E. and Robbins, R. H. (1915): J. Anat. Physiol.50,75.6. Gordon, M. (1954): J. Pediat., 45, 214.7. ,Gramse"A. E., Dockerty, M. B. and Wough, J. M. (1949):Surg. Clin. N. AIDer., 29, 1189.8. Hindmasch, F. D. (1954): Brit. Med. J., 2, 388.9. Hurst, A. F. and Johnstone, T. B. (1921): Guy's Hosp.Rep., 1, 369.10. Shanks, S. Cochrane (1950): A Textbook of X-ray Diagnosis,vol. 3, p. 353. London: H. K. Lewis.11. Snyder, W. H., Jr. and Chaffin, L. (1954): Ann. Surg., 140,373.THE FIRST THREE YEARS OF A NEUROSIS CENTREDAVID T. MACLAY, M.D., D.P.M.Assistant Psychiatrist, St. George's Hospital, Hornchurch, Essex, EnglandThe aim of this paper is to set down what have beenthe experiences gained in the opening and running of aneurosis ward, to indicate a few of the problems en-countered, and to make one or two tentative suggestionsas to how a task of this nature may be approached.The unit was opened in July 1951. It consists of a 20-bedward block within a comparatively large hospitalwhich exists otherwise for the care of chronic sick orelderly patients. Thus it has been necessary to integratethe unit into a hospital not constructed or administeredfor the treatment of psychological disability. Thehospital is laid out in separate blocks, so that the neu-rosis ward stands on its own; -but it is served by themain kitchen, occupational-therapy department, stores,and engineering, secretarial and other services of thehospital. The district is semi-urban in the outskirts ofLondon and we are half-a-mile from the bus terminusand the railway station. There is a shopping centreat 10 minutes' walking distance from the hospital andin another direction there is ready access to open fields.The 20-bed ward consists of rooms with 1, 2 or 3beds in each, a kitchen, dining room, sitting room,games room .and other amenities; and there is a con-siderable area of grassed space where patients may sitoutside in summer. Out-patient practice is a normalpart of our work and roughly one-half of the medical-treatment time is devoted to out-patients, albeit a major-ity of the latter have at one time or other been in-patientsthemselves. A small child-guidance clinic is part of theout-patient service, with a play room in the ward; butthis venture is separate from the rest of our work andwill not receive further consideration in this paper.There are no in-patient facilities for children-norcould they be satisfactorily integrated within an adultward-but adolescents are occasionally admitted.Staffing. The staff of the unit comprises one psy-chiatrist, 2 nursing sisters, 4 staff nurses, and 6 assistantnurses who need not have previous training. In spiteof the recent addition of a part-time consultant psychia-trist, the volume of out-patient work is such that the medi-cal staff is hardly adequate. A trained nursing staff of 6is generous and 5 might suffice, but we have found thatthere is not scope for more than 3 or 4 untrained nurses.It would be better if junior nurses from a traininghospital (general or mental) could come to the neurosis

Non-rotation of gut: with report of case of left-sided appendiceal abscess

https://www.ajol.info/index.php/samj/article/download/173313/162717

Non-rotation of gut: with report of case of left-sided appendiceal abscess

Abstract

Similar works

Full text

Available Versions

AJOL - African Journals Online