KGMU- INSTITUTE OF NURSING- LUCKNOW

SUB: - CHILD HEALTH NURSING

CASE STUDY ON- MALROTATION

1. Patient Bio-Data
● Name –Nishant Mishra
● Age – 8 Years
● Sex – male
● Religion- hindu
● Father’s name- Ram Pravesh Mishra
● Occupation - Farmer
● Education - 10​th​ passed
● Mother’s Occupation - House wife
● Education – 8​th​ standard
● Date of admission-31/04/2018
● Informant- Mother
● Diagnosis- Malrotation
● Surgery (if any) - Planned
● Treated by - Dr. prof. A. Wakhlu
2. Presenting complaints​ (complaints given by mother/father)-: Patient is admitted in the hospital with
the complaints of ;
1. Abdominal Pain.
2. Decreased Appetite.
3. Weight Loss.
4. Nausea and Vomiting.
3. History of present illness:
a. Mode of onset:
1. Abdominal pain with distention.
2. Refusal to take feed.
b. Sequential history of appearance of complaints:
1. Refusal to food.
2. Nausea and vomiting.
 c. Therapy /treatment received so far:

name ency n

pipzo gm otic
Dynapar esic

Metronidazole otic/Antiprotozoal

Ranitidine id

acin g otic

4. Past history​ (medical/surgical or any other): there is no past medical or surgical history.

Birth history

a. Antenatal history
1. Mother taking adequate nutrition at the time of pregnancy: Yes
2. Registered in the health facility: Yes
3. Consuming iron and folic acid: Yes
4. Regular antenatal checkups: Yes
b. Natal history
1. Type of delivery: Normal vaginal delivery
2. Baby cried/ not cried at birth: Cried
3. Instrumental delivery (where): N/A
4. weight of the child:2.6 kg
c.Postnatal history
1. Condition of the baby: Good
2. Condition of mother: Normal
3. History of any infections (PPH or any other problems): Nothing significant

5. Personal History

1. Personal hygiene of the child – Personal hygiene of the child is maintained by the parents,
and health care workers.
2. Response of child towards illness – He is lethargic.
3. Response of parents to child’s illness – Worried about their child’s disease condition.

6. Family history:

1. History of contact illness (TB/HIV): No

 2. History of similar ailment in the family: Not present
3. History of consanguinity: No
4. Birth order: First
5. Number of siblings: One
6. Illness: Other family members are healthy
7. Any death in the family: No

7. Socio-economic history:

1. Nuclear/joint family: Nuclear family

2. Who looks after child: Mother work as a primary care giver for him during hospitalization
3. Housing condition: Pacca
4. Overcrowding: Yes
5. Rural/urban: Rural
6. Water source (drinking): Hand pump
7. Smoking among family members: Father
8. Schooling of the child: Yes
9. Interactive behavior /interest of the child: Yes

8. Nutritional history:

1. Breastfeed/top feeds/mixed mode of feeding: N/A

2. Vegetarian/non-vegetarian: Vegetarian
3. Dietary intake: Chapati, Milk, Fruits, Rice, Dal.

9. Immunization: ​Pt. has immunized at birth.

1. Any known allergies- no

2. Blood transfusion till date (if any): not

PHYSICAL EXAMINATION

1. General examination:
● General condition: general condition of the patient is good, but little discomfort due to pig
tail drainage and difficulty in breathing..
● Decubitus- not present
● Built & nutrition ((PEM Grade)calculated by degree of malnutrition formula= actual weight/
expected weight×100)-76%
● Pallor - Not present
● Icterus- Not present
● Cyanosis- Not present
● Edema- Hepatomegaly is present.
● Clubbing of nails- Not present
2. Vital signs:
 ● Temperature - 99.4 F
● Pulse- 90 beat/ min
● Respiratory rate -30 breath/ min
● Blood pressure -130/90 mmHg
● SPO​2 ​- 93%
● Input - 1000 ml
● Output - 1000ml
● ABG pH - 7.47
3. Anthropometry measurement:
● Height /length: 135 cm
● Weight: 10 kg
● Head circumference: 50 cm
● Chest circumference : 65 cm
● Abdominal girth: 59 cm
● Mid arm circumference :12 cm

Condition of skin: Pink but dry skin.

Head: Normal

Condition of hairs:

● Color - Black
● Flag signs- absent
● Dryness- absent
● Pediculosis- absent
● Dandruff - absent
● Split ends- not present

Head shape: normal

● Fontanelles: Closed
● Cranial sutures: Normal
● Characteristic facies: Normal

Eyes: No any discharge

Ear: Cerumen is present and no other discharges.

Condition of lips- Dry lips

Neck: normal

Condition of nails:

● Color - Pink
 ● Shape- Normal

Head & face: Dullness

4. Systematic Assessment
a. Respiratory system
● Respiratory rate- 30 breath/ min
● Use of accessory muscles - Yes
● Type of breathing - Labored breathing
● Movement/ symmetry- Asymmetry
● Chest wall deformity - Not present
● Neck vein distension - Not present
● Trachea midline- Normal
● Air entry - Abnormal lung sounds
● Any other audible sounds - No
b. Cardiovascular system
● Apex beat - 90beat/min
● Any murmur - No
● Any other sounds- S​3​ and S​4​is present.
c. Abdomen
● Shape - Normal
● Prominent veins- Not present
● Visible peristalsis- Not present
● Bowel sounds audible- Not clear
● Distension- Present
● Abdominal wall rigidity/ guarding- Present
d. Musculoskeletal
● Joints: Normal
● Muscle tone: Present
e. Gastro nervous system:
● Stool color and character : Clay colored stool
● Diarrhea: Mild
● Constipation: Not Present
● Vomiting: Present
● Hematemesis: Not present
● Jaundice :Not Present
● Abdominal pain: Present
● Colic: Absent
● Appetite: Decreased
 f. Central nervous system
● General appearance- Dull
● Posture- Good
● Gait - Normal
● State of sensorium- Good
● Meningeal irritation:( neck rigidity/ Kernings / Brudzinski’s sign / Photophobia): Not Present
● Abnormal movements : Not present
● Sensory : Sensation to touch and pain is present

Growth & development assessment (as per the patient’s age group)- Physical , Psychological, social and
moral development of the patient is according their age group is present.

Neuromuscular maturity

Flexion of extremities- Present

Extension of extremities- Present

Turn head from side to side –Yes

Head lag in all position- No

Reflexes:

Eyes- Blinking and pupillary reflex present.

Nose-Sneeze reflex present.

Mouth and throat- N/A

Palmar and plantar reflex- N/A

Stepping reflex- N/A

Nutritional assessment: BMI of patient is.

Investigations:

S. Investigation Patient value Normal values

No.
1. Complete blood count
Hemoglobin 11.0 ​g/dl 11.5-15.5 g/dl
Total leukocyte count(TLC) 15300​ cells/mm3 4000-11000 cells/mm3
Total RBCs 3.65 Million/micro 4.5-5.5
L

1. Kidney panel
Serum urea 34.7 mg/dl 10-45
2. Serum creatinine 0.57 mg/dl 0.6-1.5
Electrolytes
Serum sodium(Na+) 137.1mmol/l 135-145
Serum potassium(k+) 3.59mmol/l 3.5-5.3
3. Liver function test
Serum bilirubin total 6.19 mg/dl 0.3-1.4
Serum bilirubin direct 0.13 mg/dl 0-0.4
 DESCRIPTION OF DISEASE CONDITION:

Definition-

Intestinal malrotation​ is a ​congenital​anomaly of rotation of the ​midgut​(embryologically, the gut undergoes

a complex rotation outside the abdomen).

Etiology- ​The exact causes are not known. It is not associated with a particular gene, but there is some
evidence of recurrence in families.

Signs and symptoms-

Patients (often infants) present acutely with ​midgut volvulus​, manifested by ​bilious​vomiting​, crampy
abdominal pain, abdominal ​distention​, and the passage of blood and ​mucus​ in their ​stools​. Patients
with ​chronic​, uncorrected malrotation can have recurrent abdominal pain and vomiting.
Malrotation can also be asymptomatic.

• The obstruction can be classified as:

• Pre-ampullary
• Post-ampullary = approximately 85%
• The pylorus is usually both distended and hypertrophic
• The bowel distal to the obstruction is collapsed
• Complete obstruction of the duodenum à the incidence of Polyhydramnios 32% to 81%.
• Growth retardation is also common

Diagnosis-

Book picture Patient picture

With acutely ill patients, consider emergency surgery ​laparotomy​ if there is a high
index of suspicion.
Plain radiography may demonstrate signs of duodenal obstruction with dilatation of Present
the proximal duodenum and stomach but it is often non-specific. ​Upper
gastrointestinal series​ is the modality of choice for the evaluation of malrotation as it
will show an abnormal position of the duodeno-jejunal flexure (​ligament of Treitz​).
In cases of malrotation complicated with volvulus, it demonstrates a corkscrew
appearance of the distal duodenum and jejunum. In cases of obstructing Ladd bands,
it will reveal a duodenal obstruction. Present
In equivocal cases, ​contrast​ ​enema​, may be helpful by showing the ​caecum​ at an
abnormal location.
It is usually discovered near birth, but in some cases is not discovered until
adulthood.​[2]​ In adults, the "whirlpool sign" of the ​superior mesenteric artery​ can be
useful in identifying malrotation.

Pre-operative care-

• Appropriate resuscitation
• Correction of fluid balance and electrolyte abnormalities
• Gastric decompression
• Parenteral nutrition via central catheter line
• Investigations:
• Complete metabolic profile,
• Complete blood cell count,
• Coagulation studies,
• An abdominal and spinal ultrasound evaluation,
• Two-dimensional echocardiography

Therapy / operation-

Treatment is possible and these are the steps taken: Resuscitate the patient with fluids to stabilize them
before surgically

● correcting the malrotation (counterclockwise rotation of the bowel),

● cutting the fibrous bands over the ​duodenum​,
● widening the mesenteric pedicle by separation of the duodenum and cecum.

With this condition the appendix is often on the wrong side of the body and therefore removed as a
precautionary measure during the surgical procedure.
One surgical technique is known as "Ladd's procedure", after Dr. William Ladd.​[4]​[5]​Long term research on
the Ladd procedure shows that even after the procedure, patients are susceptible to have complaints and
might need further surgery.

POST-OPERATIVE CARE

• Total parenteral nutrition (tpn) is continued

• Nasogastric tube output is monitored
 • Feedings may be started when the volume of the nasogastric output has diminished and its color has
lightened and it becomes clear à several days to a week
• Small feedings are then initiated with volume and concentration, Advanced as tolerated

• The majority may be discharged within one to several weeks

COMPLICATIONS

This can lead to a number of disease manifestations such as:

● Acute midgut volvulus

● Chronic midgut volvulus
● Acute duodenal obstruction
● Chronic duodenal obstruction
● Internal herniation
● Superior mesenteric artery syndrome
References-

● Wong’s, essentials of pediatric nursing, eight edition, Elsevier India private LTD, 2012.
● Gupta Suraj,’’ the short textbook of pediatric’’11​th edition, published by JAYPEE
Brothers medical publisher Pvt. Ltd.

● Brunner’s and Suddharth’s 13​th​ edition 2015 Publisher- Elseiver’s Serics medical surgical
nursing 3​rd​ edition
● Murphy FL, Sparnon AL (2006-04-01). ​"Long-term complications following intestinal malrotation and
the Ladd's procedure: a 15 year review"​. ​Pediatric Surgery International​. ​22​ (4):
326–329. ​doi​:​10.1007/s00383-006-1653-4