An unusual presentation of congenital intestinal malrotation in a nonagenarian

Abstract

HighlightsCongenital intestinal malrotation can go undiagnosed late in life and as late as into 90 years of age.CT imaging is necessary for diagnosed yet can be misleading in the presence of other ongoing pathologies.Lactic Acidosis and peritonitis in the setting of malrotation are a surgical emergency.Careful and thorough review with awareness of “classic” radiographic signs of malrotation are important for diagnosis.

A rare acute presentation of intestinal malrotation in the elderly

“…5,15 Fernandez-Moure et al however in a case report described a nonagenarian with acute presentation and no history suggestive of chronicity similar to the patient we are reporting. 3 Similar presentation was also reported by Singh et al and Emanuwa et al 2,4 Other forms of presentation reported in literature include left sided acute appendicitis (a dicey conundrum for the general surgeon in the elderly) and caecal volvulus as reported by Chuang et al and Hanna and Akoh respectively. 10,19 In a review of literature of forty-nine patients found to have malrotation with colon cancer in Japan, Nakatani et al noted that about 69.4% of the patients were noted to have non-rotation anomalies and diagnosis was made by as incidental findings during radiological investigations.…”

“…Midgut volvulus secondary to intestinal malrotation is a rare condition in the elderly with very few cases reported in literature. 3,[5][6][7][8][9][10][11][12][13][14] The first case in the elderly was probably reported in 1992 by Izes et al at the Lahey Clinic Medical Centre, USA. 15 Its rarity therefore portends a challenge in diagnosis and this mostly dependent on a high index of suspicion.…”

“…14,[28][29][30] Another issue of debate is whether an incomplete procedure (laparotomy, counter-clockwise rotation± resection and anastomosis) rather than carrying out the complete Ladd's procedure as fully described by Ladd in the very ill elderly patient with consideration of completion of the procedure later (as an elective procedure) or not at all. 2,3,19 Also, one needs to keep in mind that the general surgeon may not necessarily be as familiar with the procedure when compared to the paediatric surgeon so a paediatric surgeon's assistance may be required. The decision to carry out an incomplete Ladd procedure in our patient seems appropriate when viewed retrospectively considering the morbidity encountered in the patient in the postoperative period.…”

“…Intestinal malrotation is estimated to occur in about 0.2% of adult population or less even though the cases documented in the elderly in literature presumes that some cases may go undiagnosed all through life. [1][2][3] Midgut volvulus secondary to malrotation usually occurs in the first week of life and during infancy with about 90% of cases presenting within the first year of life. 2,4 For this reason, this condition is typically considered to occur in the pediatrics age group and hardly ever considered as a possible differential diagnosis in adults let alone the elderly.…”