Variations of intestinal malrotation in adults: A case report of midgut volvulus and literature review for the surgeon

Abstract

Introduction Intestinal malrotation is a rare congenital abnormality occurring in 0.2–1% of the population. Adult presentations comprise only 0.2–0.5% of all cases leading to diagnostic challenges and worse outcomes in adults. We present a rare case of chronic/intermittent midgut volvulus with unique anatomic findings in an adult with intestinal malrotation. Presentation of case An 18-year-old Caucasian male presented to a community hospital with abdominal pain, nausea, and vomiting. He underwent a CT scan demonstrating concern for small bowel volvulus and subsequently underwent a negative exploratory laparotomy. He was discharged post-operatively with no identified etiology for his presentation. He subsequently had multiple presentations to the ED with recurrent symptoms, review of imaging led to concern for duodenal volvulus resulting in transfer to a tertiary hepatobiliary centre. Repeat CT scan two weeks following initial presentation was consistent with intestinal malrotation with midgut volvulus. Bloodwork was unremarkable and physical exam demonstrated normal vital signs with a tender epigastrium. He underwent an exploratory laparotomy with Ladd's procedure. Intra-operative findings included a midgut volvulus and uniquely positioned Ladd's bands to the transverse colon. Post-operatively he tolerated oral intake and was discharged with three-month follow-up. Discussion Adults with intestinal malrotation suffer from delays in diagnosis and management. In contrast to the neonatal population, adults often present with vague, or chronic symptoms, which obscures the diagnosis. Conclusion The increased morbidity and mortality observed in adults with intestinal malrotation highlights the need for surgeons to appreciate the challenges associated with this diagnosis in the adult population to ensure early recognition and management.

Adult-onset congenital intestinal malrotation: A case report and literature review

“…[11][12][13][14] On the contrary, in adult patients, clinical manifestations tend to be diverse and are often nonspecific, encompassing acute, chronic acute, chronic, and incidental symptoms. [3,[15][16][17] Adult congenital intestinal malrotation typically presents as intestinal obstruction, which is accompanied by malnutrition and intestinal necrosis in some cases. [18] A study has observed that only approximately 20% of the patients exhibit acute symptoms.…”

Emergent initial presentation of congenital malrotation with midgut volvulus in 68-year-old

“…Remarkably, rates of surgery for adult-diagnosed malrotation can be less than 15%, with few adult patients ultimately undergoing the recommended Ladd’s procedure for this pathology [ 15 ]. Delayed or missed diagnosis in the unexpected adult population can lead to increased morbidity and mortality, as well as inadequate or inappropriate cares [ 14 , 15 ].…”

Midgut malrotation presenting with hyperemesis gravidarum: A case report

“…Considering the nonspecific symptoms, laboratory examinations, and the diagnosis of midgut malrotation mainly depend on plain abdominal radiography, upper gastrointestinal radiography, barium enema, computed tomography (CT), and MRI. [ 14 ] Conventional radiography is neither sensitive nor specific for malrotation, despite the possible suggestion of a right jejunal marker and colon without stool filling in the right lower abdomen. The barium meal series of the upper gastrointestinal tract remains accurate; that is, the duodenal jejunal junction does not cross the midline and lies below the level of the duodenal bulb.…”