Malrotation of the Gut in Adults: An Often Forgotten Entity

Abstract

Malrotation of the gut is a common paediatric condition that usually presents in the first month of life. However, presentation in adults is rare, and as a diagnostic dilemma quite often surprises the surgeon intraoperatively. If this condition is not timely recognized, it may result in disastrous consequences, such as gangrene of the small gut. We present the case of a 21-year-old male who presented to the emergency room with recurrent episodes of colicky abdominal pain and bilious vomiting. Contrast-enhanced computerized tomography (CT) revealed malrotation of the gut. The patient was planned for Ladd’s procedure. Malrotation in adults may present in an acute way due to midgut volvulus or may have a chronic indolent course with recurrent vomiting and abdominal pain. In patients with acute obstruction, this differential should be kept in mind, especially if the patient has no previous abdominal surgery or evidence of tuberculosis. Contrast-enhanced CT is the investigation of choice and reveals typical findings, like whirlpool sign, corkscrew sign, or reversed relation of superior mesenteric artery and vein. The treatment is surgical as failure to do so may result in intestinal gangrene. The procedure of choice is Ladd’s procedure. Every patient, even if asymptomatic, warrants this procedure as it is impossible to predict the timing of catastrophic complications.

Intestinal Malrotation with Midgut Volvulus leading to Small Bowel Obstruction in a Young Adult: A Case Report

“…The incidence of midgut volvulus due to intestinal malrotation is rare in adults with the rate approximately being 0.2%-0.5%. 3,8 This patient presented to the emergency with the presenting complaints that were suggestive of acute intestinal obstruction. There was generalized abdominal pain for past one week with abdominal distension and absolute constipation for last 2 days.…”

“…Usually a chronic presentation is more common and results in frequent visits to the hospital with crampy abdominal pain and vomiting not subsiding with conservative measures, thus posing a challenge for the surgeon. 3 Acute presentation, though uncommon, may present with intestinal ischemia and gangrene which has disastrous consequences. 10 In adults, the diagnosis requires a high index of suspicion because timely recognition is the key to survival.…”

“…Following this rotation, the bowels return to the abdominal cavity, with fixation of the duodenojejunal loop to the left of the midline and the cecum in the right lower quadrant. 3 Congenital malrotation develops when there is either partial or no rotation of the returning gut.…”

Midgut malrotation complicated by small bowel obstruction in an 80-year-old woman: A case report

“…Midgut malrotation is a congenital anomaly resulting from partial or complete failure of the midgut to complete a 270-degree counterclockwise rotation around the axis of the superior mesenteric artery (SMA) during embryological development [1,2]. The incidence is approximately 0.2–0.5% of all live births, with the majority of symptomatic cases presenting in the early weeks of life with obstructive symptoms such as abdominal pain and bilious vomiting [[3], [4], [5]].…”

“…Although malrotation is classically a pediatric problem, there have been reported cases of adults presenting with acute intestinal obstruction that demonstrate findings consistent with malrotation. Such cases appear to occur most often in young adults [[1], [2], [3],6], and occasionally in the middle-aged [2,4], with very rare instances of elderly patients [5,7]. Here we present the case of an 80-year-old woman who presented with acute-onset small bowel obstruction (SBO) and was found to have features of malrotation both on radiologic imaging and intraoperatively.…”