Introduction:
The first part of the small intestine is the duodenum. The structure connects the intestine to the stomach. The duodenum completes digestion's first phase of digestion and helps the digested food travel from the stomach and absorb nutrients and excess water from the food. It is subdivided into four sections, the superior part, descending part, the horizontal part, and ascending part. The superior part lies intraperitoneally and is enlarged proximally, known as the duodenal bulb.
What Is Duodenum Inversum?
Duodenum inversum is a rare congenital anomaly of the intestine in which the duodenal curve is reversed so that the third portion of the duodenum crosses the midline and forms a duodenojejunal junction instead of turning left; it turns right and upwards and then turns left. It is a rare condition affecting less than 20 percent of cases worldwide. In most cases, it is accidentally diagnosed. The ratio of occurrence is more in males by 4:1. It is also known as inverted duodenum or duodenal reflux.
What Causes Duodenum Inversum?
The cause or the etiology of the duodenum inversum is unknown, and it is believed to be due to the persistence of dorsal mesentery with the mobile duodenum. The normal location of the duodenojejunal junction is important in differentiating the duodenum inversum from intestinal malrotation. In most cases, the duodenum inversum is asymptomatic. It is often confused with more common anomalies of intestinal rotation.
What Are the Symptoms of Duodenum Inversum?
Duodenum inversum is frequently asymptomatic. The common symptom is epigastric pain or discomfort. Other symptoms include the following:
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Belching (the body’s way of expelling air from the upper digestive tract).
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Nausea.
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Gaseous distention (this results from bacterial growth in stagnant contents of obstructed bowel).
Dyspeptic symptoms like
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Diarrhea.
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Bilious attacks (combined symptoms that consist of abdominal pain, constipation, and headache).
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Anorexia.
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Loss of weight.
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Migraines and headaches.
Other conditions associated with gallbladder disease include duodenal ulcer, pancreatitis, and, less commonly, gastric ulcer. Many symptoms are due to stasis in the duodenum loop.
How Is Duodenum Inversum Diagnosed?
Duodenum inversum is usually an accidental finding. It is typically by a UGI or laparoscopy but can be delayed and unrecognized if the proximal duodenum is not carefully considered. The diagnosis is made by:
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Plain Radiograph: Abdominal radiographs are neither specific nor sensitive. They help in confirming the diagnosis.
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Ultrasound: Ultrasound is best used in ruling out the duodenum inversum. It helps in the diagnosis of retro mesenteric duodenum and other malrotation.
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CT (Computed Tomography): Computed tomography is done by using radio waves and computer technology and helps in identifying the malrotations and anomalies of the duodenum.
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Fluoroscopy: It is a medical procedure that makes a real-time video of movements inside the body by passing X-rays through the body over a period of time. X-rays are a form of ionizing radiation.
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Endoscopy: This procedure is done if it is needed. In most cases, it is not required.
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Biopsy: A part of the tissue is removed for external examination. It is done in cases where a biopsy is required.
What Is the Treatment for Duodenum Inversum?
The treatment of duodenum inversum in symptomatic cases is usually done by medical therapy by administering proton pump inhibitors, mainly in cases associated with ulcers and duodenitis.
Medical intervention:
In some cases, an endoscopic biopsy reveals peptic esophagitis and chronic gastritis. No evidence of duodenal obstruction is recorded in such cases. Only duodenum inversum is seen. In such cases, 20 mg of Omeprazole is prescribed daily until symptoms resolve. For symptomatic individuals with peptic ulcers with no duodenal obstruction, pharmacological interventions are advised, including antispasmodics, antiulcer agents, and antacids. But if a duodenal obstruction is present along with duodenal inversum, surgery is the only treatment of choice.
Surgical intervention:
Medical obstruction is mainstay therapy without obstruction but in cases of obstruction Surgery is indicated and in cases where the obstruction is due to fibrotic bands partial Ladd’s procedure is performed. Ladd’s procedure is a standard corrective measure for intestinal malrotation in kids that consists of a division of peritoneal bands.
Other than medical intervention, duodenum inversum is surgically corrected by mobilizing the bowel, which may include twisting of volvulus (a loop of intestine that twists around itself and the mesentery that supports it), widening the mesenteric base (a continuous set of tissues located in the abdomen), division of abnormal peritoneal bands (Ladd Bands), fixation of duodenum and cecum to retroperitoneum. In some cases, for favorable outcomes, both medical, as well as surgical interventions are done.
What Is the Differential Diagnosis of Duodenum Inversum?
The differential diagnosis of duodenum inversum is
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Acute Pancreatitis: It is a condition where the pancreas becomes inflamed over a short period of time.
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Duodenitis: Duodenitis is an intestinal condition that is caused by inflammation in the duodenum lining and can happen along with gastritis, with inflammation in the stomach lining.
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Peptic Ulcer Disease: Peptic ulcer is a sore on the lining of the stomach, esophagus, and stomach lining. This is also called a gastric ulcer.
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Functional Biliary Obstruction: Biliary obstruction refers to the impairment of bile flow from the liver to the small intestine.
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Wandering Duodenum: Wandering duodenum mimics malrotation of the duodenum. Also called duodenum inversum in infants with vomiting.
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Intestinal Malrotation: An intestinal malrotation is an abnormality that can happen early in pregnancy when the baby’s intestines do not form a coil in the abdomen. Malrotation means the intestines are twisting and causing an obstruction.
Conclusion:
Duodenum inversum is a rare congenital anomaly that responds well to conservative measures and in the absence of complete obstruction. Prokinetic agents produce good results in the duodenum inversum with features of delayed gastric emptying. The use of prokinetic agents for treating duodenum Inversum is proved successful, and it responds well to the treatment. This condition can mimic superior mesenteric artery syndrome (SMA) if it is associated with medial linear extrinsic of the duodenum. So, a complete diagnosis is important to come to the point of treatment. Management varies depending on the cause and risk associated. However, the medical line of treatment is the first choice of treatment. For successful outcomes, surgical, medical, and nutritional therapy are given together.
