Intestinal malrotation in an adult: case report

Intestinal malrotation: case description and publication analysis

Intestinal malrotation is a rare congenital anatomical anomaly that results from an abnormal bowel rotation at 10–12 weeks of embryonic development. Clinical manifestations depend on age. In children, intestinal malrotation is manifested by a midgut volvulus (Ladd syndrome). In adults, the presence of intestinal malrotation increases the risk of acute intestinal obstruction. This article presents a case of asymptomatic intestinal malrotation in a 52-year-old female patient. 

Left‐sided acute appendicitis with congenital gastrointestinal malrotation

We describe a 28‐year‐old man with acute appendicitis associated with gastrointestinal malrotation. The diagnosis was confirmed by a computed tomography scan, and he was treated by laparoscopic appendectomy without a Ladd procedure.

Midgut malrotation: a rare presentation of bowel obstruction in the adult

Intestinal malrotation is a rare congenital abnormality. Usually, patients with malrotation of the intestine present in the neonatal period or the first year of life while some may remain asymptomatic and present later in childhood or adulthood. The diagnosis is usually delayed due to the sequence of events being that of non-specific gastrointestinal symptoms, which culminates in either adhesive bowel obstruction or volvulus. A 59-year-old male diagnosed with a large, incarcerated, right inguinoscrotal hernia underwent emergency laparotomy, which revealed midgut malrotation and small bowel obstruction due to Ladd bands. A modified Ladd’s procedure and right inguinal herniorrhaphy was performed.

Intestinal malrotation in an adult patient with other congenital malformations: A case report

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Intestinal malrotation refers to aberrations in embryological midgut development.

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Patients who persist beyond infancy tend to report chronic nonspecific symptoms.

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Midgut volvulus is the acute presentation of intestinal malrotation.

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Diagnosis is made by contrast enhanced cross-sectional imaging.

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Surgical management is via the Ladd’s Procedure; laparoscopic or laparotomy.

Introduction

Intestinal malrotation refers to a variety of abnormalities which occur between weeks 5–12 of embryological development. Most presentations occur before the first year of life. However, patients persisting beyond this period report chronic abdominal symptoms making it difficult to diagnose. Although uncommon, it is important that emerging surgeons and radiologists are made aware of the diagnosis and management of adult intestinal malrotation cases.

Presentation of case

We present the case of a 40 year old patient admitted with subacute abdominal pain on a background of chronic abdominal pain, alternating constipation and diarrhoea requiring several previous hospitalisations and other congenital malformations. Outpatient computed tomography (CT) of her abdomen demonstrated intestinal malrotation and emergency laparotomy revealed Ladd’s bands compressing the duodenum. Ladd’s procedure was performed and she had an uncomplicated recovery in hospital.

Discussion

Intestinal malrotation can present acutely as volvulus mimicking an obstruction or more commonly, as chronic symptoms such as intermittent cramping, alternating constipation and malnourishment. Gold standard diagnosis in adults is by computed tomography imaging with oral contrast demonstrating inappropriate bowel position and/or inversion of superior mesenteric vessels. It is accepted that the definitive management is via the Ladd’s procedure although there is controversy regarding when laparoscopy or laparotomy should be considered.

Conclusion

Intestinal malrotation is uncommon amongst adults but its complications can be devastating if not recognised early. Ladd’s procedure either laparoscopically or via laparotomy can provide good resolution of symptoms if performed astutely.

An adult presentation of midgut volvulus secondary to intestinal malrotation: A case report and literature review

INTRODUCTION

Midgut volvulus secondary to intestinal malrotation is a rare cause of an acute abdomen in adults, with 92 confirmed cases in the literature. Incidence of malrotation is estimated 1 in 6000 live births. 64-80% of malrotation cases present in the first month of life and 90% within the first year. Adult presentation is very rare accounting for only 0.2-0.5% of cases, of which only 15% present with midgut volvulus.

PRESENTATION OF CASE

We report a rare case of a 20 year old male with spontaneous midgut volvulus secondary to congenital malrotation of the bowel. Additionally we performed a literature review and analysis of the 92 cases of adult presentations of midgut volvulus secondary to malrotation.

DISCUSSION

Of the 92 cases, average patient age was 40 years old and a 1.7:1 male:female ratio. Diagnosis of midgut volvulus was predominantly made via CT (67%) but also by ultrasound (15%) and theatre (18%). Midgut volvulus is associated with a high risk of ischaemia and necrosis of bowel supplied by the SMA (35). 19% of cases reported required a bowel resection. The case discussed in this report required a 130 cm bowel resection which is similar to the mean bowel resection length in the literature of 121 cm. Mean associated mortality rate is 5%.

CONCLUSION

This case reinforces the importance of maintaining a high index of suspicion and closely monitoring patients presenting with non-specific abdominal pain, to allow early recognition and management of rare causes of the deteriorating surgical patient.

Utility of the CT Scan in Diagnosing Midgut Volvulus in Patients with Chronic Abdominal Pain

Symptomatic intestinal malrotation first presenting in the adults is rare. Midgut volvulus is the most common complication of malrotation in the adults. Because of more differential diagnosis, Computed Tomography (CT) scan can play an important role in the evaluation of patients with this abnormality. The whirl pattern around the superior mesenteric artery found on CT scan in patients with midgut volvulus is pathognomonic and diagnostic. We describe a case of intestinal malrotation complicated by midgut volvulus in an adult patient. The preoperative CT findings were pathognomonic.