Postpartum Abdominal Pain, With a Twist

Abstract

Introduction: Intestinal malrotation classically presents in the neonatal period as acute obstruction due to intestinal, or midgut, volvulus. Midgut volvulus due to intestinal malrotation is rare in adults, with an estimated incidence of 0.2-0.6%. We present a case of a young, post-partum woman who presented with two months of abdominal pain and was found to have a midgut volvulus from intestinal malrotation. To our knowledge, this is one of the first cases of intestinal malrotation presenting as midgut volvulus after uterine involution. Case Report: A 22-year-old female with no history presented with progressively worsening post-prandial epigastric pain that started after she gave birth 2 months prior. She had an uncomplicated pregnancy and normal vaginal delivery. Over the past week, the pain had became more severe and persistent, and was accompanied by nausea and bilious vomiting. She denied weight loss and had no other constitutional symptoms. She did note constipation over the past few days but was still passing flatus. Exam revealed tenderness to palpation over the epigastrium without evidence of an acute abdomen. Labs were significant for a blood urea nitrogen of 33, hemoglobin of 16.3, and hematocrit of 50. Hepatic function panel revealed an elevated total bilirubin level of 3.5. A RUQ ultrasound done to rule out biliary obstruction showed a twisting of the proximal superior mesenteric artery (SMA) and vein (SMV) with patent flow. A CT angiography of the abdomen and pelvis showed the classic “whirlpool sign,: confirming a midgut volvulus with intestinal malrotation, with resultant duodenal obstruction. There was no evidence of bowel ischemia or perforation. An emergent surgical consultation was placed and the patient was taken down for an exploratory laparotomy with detorsion of volvulus, lysis of Ladd's bands, broadening of the mesentery, and an appendectomy.Figure: Sonographic evidence of SMV and SMA twisting.Figure: Classic “whirlpool” sign seen on CT angiography of abdomen/pelvis.Figure: Anatomic deviation of congenital malrotation; appendix seen in left upper quadrant.Discussion: Total small intestinal volvulus with malrotation classically (64-80% of the time) presents in neonates, typically within the first month of life. Symptomatic intestinal malrotation is rare in adults. This is often an incidental finding, although symptoms can range from those associated with obstruction or reflux to those found in acute intestinal infarction. CT findings can be pathognomonic if the whirlpool sign is seen. CT also allows for rapid diagnosis and surgical treatment, which is important as delayed diagnosis or treatment can result in bowel necrosis and death.