Midgut volvulus caused by intestinal malrotation; A rare cause of acute abdomen in adults. Case report

Abstract

Introduction: Acute abdomen due to midgut volvulus with intestinal malrotation is rare event with only only few cases in the literature Butterworth et al. (2018). Intestinal malrotation presented in the adulthood is reported in 0.2-0.5 %, of cases; with only 15 % f them presenting as midgut volvulus Butterworth et al. (2018). Intestinal malrotation is casued by an alteration in embryonic development between 10-12 weeks of gestation. The main alteration is anomalous position of the bowel with the small intestine residing on the right side of the abdomen, while the colon and cecum remain on the left side due to malposition of the Treitz ligament. Additionally, the ascending colon remains attached to the abdominal wall by fibrous peritoneal bands known as Ladd bands, this being a cause of midgut volvulus and intestinal obstruction.

Presentation of case: We present a 25-year-old male with failure to thrive who arrives at the ED with clinical signs and symptoms of intestinal occlusion and acute abdomen, initial resuscitation is made in ED and is transferred to OR, an exploratory laparoscopy evidencing intestinal malrotation with cecal volvulus and a Ladd procedure is made openly without PO complications.

Discussion: The gold standard for diagnosis of intestinal malrotation is the upper gastrointestinal series. However, in patients with acute abdomen associated with this pathology where is suspected intestinal ischemia and hemodynamic instability, it is essential that an emergency laparotomy be performed.

Conclusions: The diagnosis of intestinal malrotation is difficult, since many patients are asymptomatic in adulthood or present with variable GI symptoms. Therefore, it is imperative to have a high index of suspicion in patients with compatible clinical characteristics in order to perform the best therapy in time and manner.

Keywords: Intestinal; Ischemia; Ladd's bands; Malrotation; Occlusion.

Fig. 1

Abdominal X-Ray showing small bowel occlusion pattern with multiple air fluid levels, small intestine with predominance in the left hemi-abdomen and absence of air in the RLQ suggestive of malrotation.

Fig. 2

Intra-operative image showing dilated small bowel loops and midgut volvulus due to multiple bands attaching the ascending colon to the small intestine caused by intestinal malrotation.

Fig. 3

Intra-operative image showing bands attaching the small bowel to the ascending colon.

Fig. 4

Intra-operative image showing band of fibrous tissue attaching the small bowel to the right lateral wall.

Fig. 5

Intra operative image showing midgut volvulus with twisting of the small bowel around the ascending colon and cecum.

Fig. 6

Surgical specimen showing the terminal ileum, cecum and ascending colon, multiple bands are still present in the specimen.