Intestinal malrotation in an adult patient with other congenital malformations

Abstract

INTRODUCTION: Intestinal malrotation refers to a variety of abnormalities which occur between weeks 5-12 of embryological development. Most presentations occur before the first year of life. However, patients persisting beyond this period report chronic abdominal symptoms making it difficult to diagnose. Although uncommon, it is important that emerging surgeons and radiologists are made aware of the diagnosis and management of adult intestinal malrotation cases. PRESENTATION OF CASE: We present the case of a 40 year old patient admitted with subacute abdominal pain on a background of chronic abdominal pain, alternating constipation and diarrhoea requiring several previous hospitalisations and other congenital malformations. Outpatient computed tomography (CT) of her abdomen demonstrated intestinal malrotation and emergency laparotomy revealed Ladd's bands compressing the duodenum. Ladd's procedure was performed and she had an uncomplicated recovery in hospital. DISCUSSION: Intestinal malrotation can present acutely as volvulus mimicking an obstruction or more commonly, as chronic symptoms such as intermittent cramping, alternating constipation and malnourishment. Gold standard diagnosis in adults is by computed tomography imaging with oral contrast demonstrating inappropriate bowel position and/or inversion of superior mesenteric vessels. It is accepted that the definitive management is via the Ladd's procedure although there is controversy regarding when laparoscopy or laparotomy should be considered. CONCLUSION: Intestinal malrotation is uncommon amongst adults but its complications can be devastating if not recognised early. Ladd's procedure either laparoscopically or via laparotomy can provide good resolution of symptoms if performed astutely.