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.

Keywords: Adult; Case report; Intestinal malrotation; Midgut volvulus.

Fig. 1

Pre-operative CT scans venous phase demonstrating; (a, b, c) Duodenal swirl located left of the midline (d) transverse colon crossing midline twice.

Fig. 2

Intra-operative photographs demonstrating; (a) Peritoneal (Ladd's) bands coursing from the transverse colon to the right lateral abdominal wall, (b) Midgut volvulus, (c) mesentery fanned out following lysis of bands and detorsion demonstrating engorged mesenteric veins.

Fig. 3

Three months post-operative CT scans demonstrating resolution of duodenal swirl, small bowel located right of midline and large bowel located left of midline. SMV and SMA remain attenuated but no longer rotated.

Fig. 4

Schematic diagrams of the classification of intestinal malrotation and our reported case. (a) nonrotation, (b) reverse rotation, (c) incomplete rotation, (d) case reported.