Adult malrotation: a case report and review of the literature

Abstract

Midgut malrotation is an anomaly of fetal intestinal rotation that usually presents in the first month of life. It is rare for malrotation to present in adulthood. Symptomatic patients present either acutely with bowel obstruction and intestinal ischemia with a midgut or cecal volvulus, or chronically with vague abdominal pain. Chronic symptoms can often make the diagnosis difficult. Findings diagnostic of malrotation are described using several modalities such as barium studies, computed tomography (CT) scans, angiography, and often emergent laparotomy. Treatment remains the Ladd procedure originally described by Dr. Ladd in 1936. Complete resolution of acute obstruction or chronic abdominal pain is the result of a high index of suspicion for malrotation, appropriate diagnostic studies, and aggressive definitive surgical treatment. We present a case of malrotation in an adult who presented with chronic abdominal pain. Midgut malrotation is a congenital anomaly referring to either lack of or incomplete rotation of the fetal intestines around the axis of the superior mesenteric artery during fetal development. Most patients present with bilious vomiting in the first month of life because of duodenal obstruction or a volvulus. It is rare for this condition to present in adulthood. The true incidence in adults is difficult to estimate because most patients who remain are asymptomatic and their conditions are, therefore, never diagnosed. A literature review by von Flue et al cites 40 cases from 1923 to 1992. Patients who are symptomatic often present either acutely with bowel obstruction and intestinal ischemia with a midgut or cecal volvulus or chronically with vague abdominal pain. These symptoms are caused by peritoneal bands first described by Ladd in 1932. These bands run from the cecum to the right lateral abdominal wall. We present a case of malrotation in an adult who presented with chronic abdominal pain.