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Presented to the emergency department with cramping, constant right abdominal pain. An avid cyclist, his symptoms began 12 hours before admission. A day prior, the patient started experiencing light, constant abdominal pain in the afternoon but decided to go cycling During the night, the abdominal pains grew increasingly worse in intensity and were primarily localized to the right iliac fossa with associated vomiting without relief of nausea. His last bowel movement the day before was described as normal. He had a history of surgery as a child operated on for umbilical hernia which had later recurred, bilateral open surgery due to inguinal hernia and appendectomy. The patient had also been hospitalized 2 years prior with upper abdominal pain where Mallory-Weiss lesions were discovered during gastroscopy and a year after that hospitalized with similar abdominal pain without a diagnosis.
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Contrast CT scan of the abdomen showed malrotation of the small intestine with the jejunum and a large part of the ileum placed on the right side of the abdomen with dilated, fluid-filled ileum loops. In addition, signs of low signal in the mesentery gave suspicion of peritonitis and free intraabdominal fluid. Small air bubbles were seen in the right hypochondrium. There were visualized dilated loops of ileum up to the ileocecal junction with “fecal sign”. Based on the diagnosis of malrotation, the patient consented for exploratory laparoscopy with the possibility of conversion to laparotomy.
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Intestinal malrotation is a congenital anomaly resulting in the lack of or incomplete rotation of the fetal intestine around the axis of the superior mesenteric artery. Symptoms usually present in early childhood, but are rarely seen in adults. Rotational anomalies, which may or may not be symptomatic, are estimated to occur in between 1/200 and 1/500 live births [1,2] and incidentally are discovered later in life at surgery for other conditions [3-5]. Symptomatic malrotation is estimated to occur in 1/6000 live births [1,6]. Rare adult cases have been reported [7-10]. Adult-age intestinal malrotation has a nonspecific presentation and is difficult to diagnose due to progressively decreasing suspicion for malrotation in the older population.
Intestinal malrotation is any deviation from the normal 270 degree counterclockwise rotation of the midgut around the superior mesenteric artery that begins at the 6th gestational week with a prolapse into the umbilical cord and return of the midgut into the abdominal cavity between the 10th and 12th week. This rotation has been divided into 3 stages and anomalies in rotation are associated with each stage:
Stage I anomalies are nonrotation anomalies where the midgut fails to return to the abdomen, developing an omphaloceles.
Stage II anomalies are duodenal malrotation anomalies that include nonrotation, malrotation, reversed rotation and paraduodenal hernias.
Stage III anomalies are combined duodenal and cecal malrotation anomalies that include an unattached duodenum, mobile cecum, internal hernias, midgut volvulus, incomplete fixation of hepatic flexure of the colon, intermittent duodenal obstruction by Ladd bands and an unattached small bowel mesentery [11,12]. Ladd bands are bands fixing the duodenum to the retroperitoneum and cecum that continue to form in spite of incomplete rotation of the cecum .
- 1. Warner B. Malrotation. In: Surgery of Infants and Children: Scientific Principles and Practice, Oldham KT, Colombani PM, Foglia RP (Eds), Lippincott Williams & Wilkins, Philadelphia 1997. p.1229.
- 2. Torres AM, Ziegler MM. Malrotation of the intestine. World J Surg 1993;17:326-331.
- 3. Parish A, Intestinal malrotation, Medicine, vol. 20, pp. 1–16, 2002.
- 4. Fukuya T, Brown BP, Lu CC. Midgut volvulus as a complication of intestinal malrotation in adults. Dig Dis Sci 1993;38:438-444.
- 5. Spigland N, Brandt ML, Yazbeck S. Malrotation beyond the neonatal period. J Pediatr Surg 1990;25:1139-1142.
- 6. Berseth CL. Disorders of the intestines and pancreas. In: Avery's Diseases of the Newborn, 7th, Taeusch WH, Ballard RA (Eds), WB Saunders, Philadelphia 1998. p.918.
- 7. Sheikh F, Balarajah V, Ayantunde AA. Recurrent intestinal volvulus in midgut malrotation causing acute bowel obstruction: A case report. World J Gastrointest Surg. 2013;5 (3): 43-6. doi:10.4240/wjgs.v5.i3.43 - Free text at pubmed - Pubmed citation
- 8. Papaziogas B, Patsas A, Paraskevas G, Tsiaousis P, Koutelidakis I, Christoforakis C, Atmatzidis K. Adult Intestinal Malrotation: A Case Report. The Internet Journal of Surgery. 2008 Volume 19 Number 2.
- 9. Khara HS, Kothari ST, Gruss CB, Langnas A, Schafer DF and McCashland TM. True versus Pseudo-Intestinal Malrotation: Case Series and Review. ACG Case Rep J 2013;1(1):29–32. doi:10.14309/crj.2013.12. Published online: October 8, 2013.
- 10. Bektasoglu HK, Idiz UO, Hasbahceci M, et al. Midgut Malrotation Causing Intermittent Intestinal Obstruction in a Young Adult, Case Reports in Surgery, vol. 2014, Article ID 758032, 3 pages, 2014. doi:10.1155/2014/758032.
- 11. Gohl ML, DeMeester TR. Midgut nonrotation in adults. Am J Surg 1975;129:319-323.
- 12. Amaral L, Quintanilha R, Bernardo L, et al. Intestinal malrotation in the elderly. Am Surg. 2009;75:631–3.
- 13. Ladd WE. Congenital obstruction of the duodenum in children. N Engl J Med 1932;206:273-283.
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