Volvulus of the Small Bowel due to Malrotation during Pregnancy : a Case-Report Corresponding

Volvulus occurring during pregnancy is a rare complication, still potentially lethal nowadays for both the mother and child due to several, early arising complications. We report here a case of small bowel volvulus in a 28 weeks and 4 days, 29 years-old, pregnant woman with a past medical history of appendectomy in her childhood. Patient presented in emergency department with abdominal pain and abnormal hepatic tests. Cholangio-MRI suggested bowel obstruction due to volvulus that was confirmed by gastroscopy (showing the obstruction) and intestinal MRI. Patient was first treated by laparoscopy but, due to a very complicated abdominal status with the presence of several adhesions of the small bowel, surgery was changed to an open laparotomy, which allowed discovery and repositioning of small bowel malrotation and removal of adhesions. Both patient and the foetus were healthy after surgery and the patient was then discharged. In the light of this particularly rare case of small bowel volvulus due to malrotion, we will describe the pathology of bowel obstruction and more particularly volvulus during pregnancy and discuss its diagnosis and treatment. Paul E Constanthin 1 , M. Darouichi 2 * 1.Deartment of fundamental Neurosiences, University Medical Center, University of Geneva, Geneva, Switzerland. 2.Medical institute radiology and gynecology ,Genrva, Switzerland. DOI : 10.14302/issn .2574-4526.jddd-17-1497 Volvulus of the Small Bowel due to Malrotation during Pregnancy: a Case-Report Corresponding author: Darouichi Mohammed ,E-mail: Mohammed.Darouichi@ne.ch


Introduction
Bowel obstruction occurring during pregnancy (with an incidence between one in 1500 and one in 66'431 (Aftab et al, 2014)  1 is a rare complication potentially lethal for both the mother and child.Less than a hundred cases of this pathology have been reported and its causes can be very different, one of them, but not the most frequent, being intestinal volvulus.Intestinal volvulus most frequently interests the sigmoid colon due to its modified position during pregnancy, particularly its displacement during third trimester, but other regions have been reported to be involved.Due to the rarety of this entity and the absence of any specific symptom or laboratory test, early diagnosis, as well as treatment, remains of extremely complicated despite their importance (Aftab et al, 2014) 1 .We report here a new case of a rare form of small bowel volvulus due to a malrotation in a 28 weeks and 4 days pregnant, 29 years-old female with a past medical history of appendicitis.We then discuss diagnosis of volvulus during pregnancy and its treatment, which both need to be initiated early during patient management to not risk a tragic outcome for both mother and child.

Case-Report
A 28 weeks and 4 days pregnant, 29 years-old female, known for an L4-L5 discopathy and a past history of surgery for appendicitis at the age of 10  The small intestine, which showed no sign of ischemia, was sutured and adhesions were completely removed.
A few hours after the surgery, the patient presented with uterine contractions every two minutes and uterine ultrasonography showed a 33mm cervix.
Tocolysis was immediately given with good results and the contractions definitely ceased and did not reappear two days later when treatment was stopped.During her stay, the patient presented with left basal pneumonia that was treated with antibiotherapy.She completely recovered during the following days and was then discharged with no further complication.The rest of her pregnancy went without any other complication and the patient delivered with instrumentation (Kiwi-sucker) at the age of 40 weeks and 0 days due to a suspect cardio-tocogramm and absence of delivery progression..In our case, we were able to supress contractions with tocolytics and no premature delivery was needed.
In this article, we presented a case of small bowel volvulus during pregnancy that not only confirmed some already known facts about this pathology but also

(
right-positioned appendix, not perforated), consulted with vomiting and abdominal pain in the epigastric region.Eating and drinking had become impossible at that point.Blood tests revealed pathologically elevated white blood cells count (11.4 G/l for a normal value of 4-10 G/l) and elevated hepatic tests.Preeclampsia and HELLP syndrome were ruled out, as were frequent causes for hepatitis (virus, medicines, auto-immunity).Abdominal echography did not reveal any sign of cholecystitis or pancreatitis and testing for urinary cause was negative.The second blood tests revealed a worsening of the hepatic tests, reason why the patient underwent a cholangio-MRI.This test did not reveal any biliary lesion but volvulus was suspected due to apparent intestinal malrotation.Obtruction was confirmed by gastroscopy (without scope) and situated at the level of the jejunum.Final confirmation of obstruction and its position in the abdomen was also obtained through intestinal MRI (see Figures 2A, 2B

and 3 )
. During this time, the patient never displayed any gynaecological signs and foetal echography revealed a foetus with cephalic position, weighting 1300g and a posteriorly inserted healthy placenta with a Manning score of 10/10.The patient was referred for surgery.She underwent an exploratory laparoscopy that revealed multiple adhesions of the small intestine.Volvulus of the small intestine was identified just at the level of the duodeno-jejunal angle, situated on the right side of the aorta.Removal of the adhesions was attempted but ended up causing a small lesion of the small intestine, prompting the transformation of the laparoscopy into an open laparotomy.The laparotomy revealed a volvulus of the small intestine with common mesentery, with encircling of the caecum, the last part of the ileum and the beginning of the jejunum by the omentum.Resolution of the volvulus showed absence of intestinal rotation at the duodeno-jejunal angle, confirming the presence of malrotation.Mesentery was repositioned (without Ladd's procedure) and fixation of the right colon to the right peritoneum was performed.

Fig. 2 -
Fig. 2-A.Axial contrast-enhanced MRI scans show characteristic whirpool appearance of bowel and mesentery wrapping around superior mesenteric artery

Fig. 1 .
Fig. 1.-Schematic drawings of normal rotation and malrotation (from Pickhart et Bhalla, 2002).A, Drawing shows that normal 270° rotation and fixation of midgut results in familiar positioning of bowel with broad mesenteric attachment (dotted line).B, Drawing shows that malrotation results in malpositioned bowel and narrow base of mesenteric fixation (dotted line), which is prone to midgut volvulus.Abnormal fibrous peritoneal bands of Ladd (curved lines) that attach to right colon predispose to internal hernia in older patients.
enlightened new ones, notably on the risks of the nonspecificity of blood tests.Indeed, in front of a patient with high-level suspicion (due to medical history or symptoms), rapid decision to perform surgery should be taken to avoid tragic outcomes.All in all, our case shows that there is still much to understand about bowel obstruction during pregnancy (and particularly small bowel volvulus) and, in the interest of the patients, diagnosis should be made promptly to prevent the aforementioned dramatic outcomes and we are absolutely convinced that further refinement of the actual diagnosis technics and development of future ones is of paramount importance.Conclusion Small bowel volvulus is a rare, potentially lethal complication of pregnancy.Particular attention should be taken in front of any pregnant woman presenting with gastro-intestinal signs and prompt diagnosis and treatment are the key to a positive outcome of such pathology.

Freely Available Online www
.openaccesspub.org| JDDD CC-license DOI : 10.14302/issn .2574-4526.jddd-17-1497 Vol-1 Issue 3 Pg.no.-37 Discussion Intestinal obstruction occurring during pregnancy is a rare (its incidence being between one in 1500 and one in 66'431 (Aftab et al, 2014) 1 , extremely dangerous complication.In their review of the literature, particularly the last trimester (Wax et a, 1993; Aftab et al, 2014; Shui et al 2011). 14,1 ,12However, the entire gastro-intestinal tract can in fact be at risk for volvulus during pregnancy (Cong et al, 2014). 4The risk is even higher in conditions in which a reduction in the available space is present, like congenital malrotation (Fig 1, those signs and intestinal obstruction by small bowel volvulus may be overlooked.Thus, a complete and thorough physical examination completed by blood tests and imagery should always be considered in front of such a patient.One particular point that should make clinicians extremely cautious is that blood tests can be

Freely Available Online www
.openaccesspub.org| JDDD CC-license DOI : 10.14302/issn .2574-4526.jddd-17-1497 Vol-1 Issue 3 Pg.no.-39 should be started at the earliest time possible. 16.Foetal health should also always be monitored and tocolysis should be administered in the case of contractions, as was done in this case.If necessary, delivery of the foetus might be done at the same time as the surgery but it does not always suppress the risk of small bowel volvulus.Indeed, small bowel volvulus can also occur after delivery (Shere et Abulafia, 2001, Coder et al 1976; Ranjan et al, 1993)