Case report of congenital intestinal malrotation in an adult discovered three months status-post appendectomy

Abstract

Introduction and importance: Intestinal malrotation is a congenital anomaly primarily diagnosed in children, with limited cases reported in adults. Prompt recognition is necessary to prevent life-threatening complications including bowel ischemia and death. We present a rare case of adult intestinal malrotation highlighting difficulty in diagnosis and surgical management.

Case presentation: A 37-year-old Caucasian woman presented with a 3-day history of worsening diffuse abdominal pain, three months status-post laparoscopic appendectomy. CT scan with contrast of the abdomen and pelvis demonstrated small bowel mesenteric swirling and descending duodenal transition point. Differential diagnosis included intestinal malrotation versus small bowel obstruction. Pre-operatively, the patient expressed frustration with years of abdominal pain and lack of improvement. Treatment with open surgical small bowel detorsion and ligation of the Ladd's bands was performed, after initial laparoscopic intervention was complicated by enterotomy. The patient recovered well post-operatively with final diagnosis of intestinal malrotation with midgut volvulus. Discharge home was delayed due to polysubstance withdrawal. Post-operatively, the patient reported immediate relief of symptoms which persisted at 2-week and 2-month follow-ups.

Clinical discussion: Few reports of congenital malrotation diagnosed in adulthood are reported. This highlights the importance of evaluating all patients for malrotation when the appendix is found outside of the normal positioning in the RLQ, as surgical correction of malrotation is of utmost importance in such patients.

Conclusion: Clinicians should consider intestinal malrotation in adults with recurrent vague abdominal symptoms. To our knowledge, this is the first report of congenital malrotation discovered in an adult after prior appendectomy.

Keywords: Case report; Complications; Intestinal malrotation; Ladd's bands; Volvulus.

Fig. 1

CT images from prior ED visit 2 months before hospital admission for abdominal pain with no mention of malrotation.

Fig. 2

CT images from ED on hospital admission day 1 showing mesenteric swirling, SBO, and possible midgut volvulus.

Fig. 3

Intraoperative visualization of the midgut volvulus with twisting of the mesentery around one of the fibrous bands.

Fig. 4

Ladd's bands connecting the small bowel to the anterior abdominal wall.