Midgut Volvulus as Presentation of Intestinal Malrotation in an Elderly Patient

Abstract

Congenital intestinal malrotation is an incomplete rotation and fixation of the midgut during embryogenesis. Most commonly diagnosed during infancy, it is rarely reported in adults with an estimated incidence of 0.0001 and 0.2%. A 77 year old man presented to the ED with symptoms of gastrointestinal(GI) bleeding, including, anemia and melena. At prior hospitlizations the patient had several upper and lower endoscopies showing multiple AVMs in the stomach and duodenum. Patient was admitted and subsequently underwent a push enteroscopy that did not reveal any obvious source of bleeding. Six hours post-procedure, he developed diffuse severe abdominal pain with abdominal distention and tenderness over the RUQ. CT abdomen demonstrated a “mesenteric swirl” concerning for mid-gut volvulus. He underwent emergent exploration and was found to have a complete malrotation of the small and large bowel with classic Ladd's bands adhesions and the appendix in the LLQ. Mid-gut volvulus was reduced, the congenital adhesions divided and the appendix removed. The early post-op period was complicated by high-grade small bowel obstruction warranting re-operation on POD#7. Abdominal re-exploration revealed multiple adhesions of the small bowel, which were lysed as well as a severe kink at the 4th portion of the duodenum which was to the right of the SMA. Patient had a complicated, prolonged hospital course requiring TPN and was discharged on POD# 37. Unlike infant population, adult patients with intestinal malrotation present with more vague and chronic symptoms like recurrent abdominal pain associated with nausea, vomiting, frequent diarrhea, bloating, early satiety and upper or lower gastrointestinal bleeding. Acute volvulus can be the initial presentation in 10-15% of adults. CT abdomen with oral and IV contrast is the imaging of choice for diagnosis. The classic “whirl” sign, consisting of mesentery and superior mesenteric vein around the superior mesenteric artery, is highly suggestive of midgut volvulus. Surgical management typically involves counterclockwise detorsion of bowel, lysis of Ladd's bands and appendectomy to prevent morbidity of future diagnostic delay. Non-operative management of asymptomatic patients is reasonable. We present this case to increase awareness of malrotation as a possible cause of chronic abdominal pain and acute volvulus in the adult population.1468_A Figure 1. CT abdomen showing Intestinal malrotation with suspected midgut volvulus1468_B Figure 2. CT abdomen: showing whirlpool sign at coronal view1468_C Figure 3. Findings at exploratory laparotomy