Page 60 - World Journal of Laparoscopic Surgery

CASE REPORT
Congenital Midgut Malrotation Presenting as Acute Duodenal

Obstruction in an Adult—Laparoscopic Management

1
Rafique U Harvitkar , Abhijit Joshi 2

AbstrAct
Background: Intestinal malrotation is a congenital anomaly, wherein the midgut fails to rotate completely or partially during the early
embryological developmental phase. The rotation is usually counterclockwise at 270° around the axis of the superior mesenteric artery (SMA).
Malrotation is most commonly seen in pediatric population with the majority of patients presenting in their early childhood before the first
year of life. Acute duodenal obstruction due to midgut malrotation in an adult is a rare manifestation. Therefore, midgut malrotation should be
the differential diagnosis in an adult with bowel obstruction.
Case description: We present a case of a 26-year-old male who presented with acute-onset abdominal pain with multiple episodes of bilious
vomiting. Contrast-enhanced computed tomography of the abdomen (CECT) revealed intestinal malrotation with all parts of the duodenum
(D1–D4) toward the right of the midline. The patient underwent an emergency laparoscopic Ladd’s procedure. Postoperative recovery was
uneventful.
Conclusion: Adult patients with vague abdominal symptoms should raise a high index of suspicion for malrotation. An early and prompt
diagnosis will prevent fatal complications associated with this disease and can be managed laparoscopically by Ladd’s procedure.
Keywords: D1 to D4 of the duodenum, Embryologic development, Intestinal malrotation, Ladd’s band, Ladd’s procedure.
World Journal of Laparoscopic Surgery (2021): 10.5005/jp-journals-10033-1439

IntroductIon 1,2 Department of General and Laparoscopic Surgery, Dr LH Hiranandani
Intestinal malrotation is a congenital anomaly, wherein the Hospital, Mumbai, Maharashtra, India
midgut fails to rotate completely or incompletely during the early Corresponding Author: Rafique U Harvitkar, Department of General
embryological developmental phase. Developmental failure of and Laparoscopic Surgery, Dr LH Hiranandani Hospital, Mumbai,
the ligament of Treitz leads to the presence of duodenojejunal Maharashtra, India, Phone: +91 8879525195, e-mail: dr_rafique639@
flexure (DJ) along with the small bowel toward the right side of the yahoo.com
vertebrae. Intestinal malrotation affects 1 in every 500 neonates, How to cite this article: Harvitkar RU, Joshi A. Congenital Midgut
1,2
and 65–85% of malrotation cases present within 4 weeks of life. Malrotation Presenting as Acute Duodenal Obstruction in an Adult—
However, 90% of cases present within the first year of life. 3 Laparoscopic Management. World J Lap Surg 2021; 14(1):61–64.
Intestinal malrotation presenting in an adult is a very rare Source of support: Nil

entity. It accounts for 0.0002% to 0.02% of all cases of intestinal Conflict of interest: None
3
malrotations. Most of these cases are asymptomatic and diagnosed
incidentally on radiological imaging or unrelated surgery. Hence, it is
difficult to determine the exact counts of patients with malrotation.
However, a few of these patients may present with acute or episodes of bilious vomiting for 2 days. For 2 years, he had intermittent
chronic symptoms. Acute symptoms include nausea, vomiting, dull aching epigastric pain, diagnosed as “chronic gastritis.”
abdominal pain, abdominal distension, constipation, or obstipation. The patient did not experience fever, altered bowel habits, or
Whereas, chronic symptoms include intermittent dull aching melena. He did not give any history of previous surgeries. He was
or crampy abdominal pain and altered bowel habits (diarrhea/ hemodynamically stable.
constipation) with general weakness. The surgeon should be Physical examination revealed abdominal distension, epigastric
vigilant while evaluating an adult patient with acute or chronic tenderness, and an empty rectum. The patient was admitted
symptoms of intestinal obstruction. Undiagnosed cases can lead for further evaluation with a provisional diagnosis of acute
to fatal complications, such as bowel ischemia or necrosis. exacerbation of chronic gastritis. He was kept nil by mouth and
In 1932, Ladd was the first to discover the peritoneal bands started on intravenous fluids, proton pump inhibitors, antiemetics,
4
responsible for midgut malrotation, hence named Ladd’s bands. and continuous nasogastric tube aspiration. His symptoms started
We herein report a case of acute intestinal (duodenal) obstruction progressively worsening despite 2 days of conservative medical
caused by midgut malrotation.
management. Hence, he was investigated further. Routine blood
investigations were unremarkable.
cAse descrIptIon
A 26-year-old male with no comorbidities was admitted to the Radiological imaging:
emergency ward with acute-onset abdominal pain and multiple • The erect abdominal X-ray revealed a “double-bubble sign.”

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