A rare presentation of midgut malrotation as an acute intestinal obstruction in an adult: Two case reports and literature review

Abstract

Introduction: Midgut malrotation is a congenital anomaly presenting mainly in the childhood. Its presentation as an acute intestinal obstruction is extremely rare in adults usually recognized intra-operatively, therefore a high index of suspicion is always required when dealing with any case of acute intestinal obstruction.

Presentation of case: We report two cases of young adults who presented with symptoms of acute intestinal obstruction and were diagnosed intra-operatively as cecal volvulus and paraduodenal hernia, respectively, caused by midgut malrotation. Post-operative CT scan confirmed these findings.

Discussion: Malrotation of the intestinal tract is a product of an aberrant embryology. The presentation of intestinal malrotation in adults is rare (0.2-0.5%). Contrast enhanced CT can show the abnormal anatomic location of a right sided small bowel, a left-sided colon and an abnormal relationship of the superior mesenteric vein (SMV) situated to the left of the superior mesenteric artery (SMA) instead of to the right.

Conclusion: Anomalies like midgut malrotation can present as an operative surprise and awareness regarding these anomalies can help surgeons deal with these conditions.

Fig. 1

(1) X-ray showing cecal volvulus. (2) Cecal volvulus showing dilated cecum with appendix. (3) Right side of peritoneal cavity showing absence of ascending colon, hepatic flexure, and transverse colon. Doudeno-jejunal flexure can be seen abnormally located on the right side. Kidney can also be visualized.

Fig. 2

(1) A paraduodenal hernia. A large defect with a loop of small intestine trapped in it can be seen. (2) A CT scan showing the abnormal relationship of superior mesenteric vein (SMV) with the superior mesenteric artery (SMA).