Acute presentation of intestinal malrotation in adults: a report of two cases

Late presentation of midgut malrotation in a young adult

Midgut malrotation is a congenital anomaly due to partial or complete failure of rotation of the midgut in fetal life. Majority of the cases present in the neonatal period and 90% within the first year. Adult presentation is rare and the true incidence is unknown as some cases pass undiagnosed. Whirlpool sign is pathognomic for midgut malrotation and management involves surgery.

Adult Presentations of Congenital Midgut Malrotation: A Systematic Review

BACKGROUND

Adult midgut malrotation is a rare cause of an acute abdomen requiring urgent intervention. It may also present in the non-acute setting with chronic, non-specific symptoms. The objective of this study is to identify the clinical features, appropriate investigations and current surgical management associated with adult malrotation.

METHODS

A systematic review was conducted according to PRISMA guidelines, identifying confirmed cases of adult malrotation. Patient demographics, clinical features, investigation findings and operative details were analysed.

RESULTS

Forty-five reports met the inclusion criteria, totalling 194 cases. Mean age was 38.9 years (n = 92), and 52.3% were male (n = 130). The commonest presenting complaints were abdominal pain (76.8%), vomiting (35.1%) and food intolerance (21.6%). At least one chronic symptom was reported in 87.6% and included intermittent abdominal pain (41.2%), vomiting (12.4%) and obstipation (11.9%). Computerised tomography scanning was the most frequent imaging modality (81.4%), with a sensitivity of 97.5%. The whirlpool sign was observed in 30.9%; abnormalities of the superior mesenteric axis were the commonest finding (58.0%). Ladd's procedure was the most common surgical intervention (74.5%). There was no significant difference in resolution rates between emergency and elective procedures (p = 0.46), but length of stay was significantly shorter for elective cases. (p = 0.009). There was no significant difference in risk of mortality, or symptom resolution, between operative and conservative management (p = 0.14 and p = 0.44, respectively).

CONCLUSION

Malrotation in the adult manifests with chronic symptoms and should be considered as a differential diagnosis in patients with abdominal pain, vomiting and food intolerance.

Laparoscopic surgery for repeated cecal volvulus with intestinal malrotation: A case report

This is the first report of laparoscopic surgery for an advanced-age patient with cecal volvulus accompanied by intestinal malrotation. A 96-year-old woman who had previously undergone laparotomy for cecal volvulus underwent emergency laparoscopic surgery for recurrent volvulus. Because the cecum was about to rupture but not ischemic, we untwist the intestinal volvulus and fixed the cecum to the abdominal wall with a single suture. Five days after the surgery, the volvulus between the suture and the hepatic flexure of the colon recurred. We performed a second laparoscopic surgery in which we fixed the right side of the colon to the abdominal wall after diagnosing intestinal malrotation. Given its positioning, the sign of malrotation would not have been visible on preoperative CT images. As shown by this case, intestinal malrotation might lie behind the repeated cecal volvulus, and laparoscopic surgery may be a good option for volvulus with intestinal malrotation, even in cases with obstruction.

A Case Report on Left-sided Appendicitis with Intestinal Malrotation

Acute appendicitis is a mimicker of a wide range of gastrointestinal and genitourinary pathologies. The diagnosis becomes more challenging when it is associated with intestinal malrotation. A rare case of left-sided acute appendicitis with asymptomatic undiagnosed intestinal malrotation is reported. A 32-year-old male without known comorbidities presented with left-sided abdominal pain. Abdominal ultrasonography and computerized tomography scans showed intestinal malrotation with acute appendicitis. Exploratory laparotomy and appendectomy with Ladd's band release via midline incision were performed, and the patient had no issues on follow-up. Given the rarity of acute appendicitis associated with intestinal malrotation, an increase in awareness of this anatomical variant is essential among emergency physicians, radiologists, and surgeons for prompt diagnosis and timely intervention.

Incidental intestinal malrotation in an adult: Midgut volvulus

Intestinal malrotation is a developmental anomaly characterized by a midgut fixation disorder and failure to complete its normal fetal rotation around the superior mesenteric artery inside the peritoneal cavity. Malrotation is a rare cause of mechanical intestinal obstruction in adults. It may manifest as an emergency condition or with chronic abdominal symptoms. Although its diagnosis remains difficult, early diagnosis and treatment usually yield favorable outcomes. Intestinal malrotation rarely has an asymptomatic course, in which the diagnosis is usually made incidentally. Multislice computed tomography is quite helpful for making a correct diagnosis. In this study, we reported a 56-year-old patient incidentally who was detected to have intestinal malrotation and was managed symptomatically after presenting at our clinic with signs and symptoms of intestinal obstruction; we also provided a discussion of the relevant literature.

Idiopathic Sclerosing Encapsulating Peritonitis: A Rare Cause of Subacute Intestinal Obstruction

We present a case of a previously healthy 50-year-old gentleman who had recurrent vomiting and abdominal pain of two-month duration. The patient was subsequently diagnosed with abdominal cocoon on computed tomography. Idiopathic sclerosing encapsulating peritonitis, also known as abdominal cocoon, is a rare cause of small bowel obstruction. Visualization of variable encasement of the small bowel loops by a characteristic membranous sac, either preoperatively with cross-sectional imaging or intraoperatively, is the key to diagnosis. This is a highly treatable condition; surgical excision of the sac with adhesiolysis facilitates a full recovery in affected patients.

Unusual presentation of left sided acute appendicitis in elderly male with asymptomatic midgut malrotation

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Midgut malrotation in adulthood is rare, with reported incidence 0.1–0.5%.

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Acute appendicitis with undiagnosed midgut malrotation has been sparsely described.

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Presenting symptoms are often atypical which delay diagnosis.

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Early recognition with appropriate imaging is key to diagnosis and appropriate management.

Introduction

Acute appendicitis in the setting of midgut malrotation is uncommon. Midgut malrotation commonly presents within the first month of life. A minority remain asymptomatic and may present with concomitant abdominal pathology making diagnosis difficult.

Presentation of case

This paper reports a rare case of a 73-year-old male diagnosed with acute appendicitis and asymptomatic MM .The patient underwent a laparoscopic appendectomy, but had an unplanned return to theatre for washout of post-operative intra-abdominal haematoma.

Discussion

Midgut malrotation is commonly described by the stringer classification and type 1a is the most common in adults. There have only been a handful of documented cases of acute appendicitis with midgut malrotation occurring in the adult population. Previous delay in diagnosis has led to a delay in definitive management. Both laparoscopic and open surgery has been used in the past.

Conclusion

Acute appendicitis with malrotation should be considered in elderly patients presenting with atypical signs and symptoms. Imaging offers significant advantage for timely and definitive management.

Progression of malrotation into volvulus in an adult after appendectomy

Among the pediatric population malrotation is the most common cause of volvulus. This paper describes a case of adult malrotation, which progressed to volvulus shortly after appendectomy. It also reviews clinical presentations and diagnostic tools, discusses the recommended management, and considerations when addressing of this rare malady.

Carcinoma of the colon in an adult with intestinal malrotation

Colon cancer is the third most common cancer in the USA. Intestinal malrotation diagnosed in adulthood was, until recently, a very rare phenomenon. While patients may present with intestinal obstruction or abdominal pain, the diagnosis is now often made as an incidental finding by computed tomography (CT). Surprisingly we found only seven case reports of carcinoma of the colon in patients with malrotation; CT failed to make the preoperative diagnosis in a majority. Laparoscopic colon surgery is rapidly becoming standard of care for colon cancer. We present a case of carcinoma of the colon in an adult that thwarted attempts at laparoscopic resection due to failure to recognize malrotation preoperatively. The literature is reviewed, and the implications of malrotation in patients with colon cancer are examined.