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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 2  |  Issue : 1  |  Page : 29-31

Malrotation with midgut volvulus and bowel gangrene in a 45-year-old man


Department of Surgery, Barau Dikko Teaching Hospital, Kaduna State University, Kaduna, Nigeria

Date of Web Publication13-Sep-2017

Correspondence Address:
Stephen Akau Kache
Department of Surgery, Division of Paediatric Surgery, Barau Dikko Teaching Hospital, Kaduna State University, Kaduna
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/archms.archms_2_16

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  Abstract 


Midgut volvulus due to intestinal malrotation is a rare occurrence in adult life. Malrotation is a congenital, developmental anomaly that results from an arrest of the physiological rotation of the gut through 270°. It is often thought that complications due to it, present themselves early during childhood and rarely occur among adults. However, a few cases have occurred and have been reported among adults. When it does occur in adults, it is often associated with catastrophic consequences. We present the case of a 45-year-old man with malrotation resulting in midgut volvulus. Our patient is a 45-year-old man, who presented with sudden onset of colicky abdominal pain and abdominal swelling of 24 h duration. He had been having recurrent abdominal pain since childhood. Physical examination revealed a patient in shock with markedly distended abdomen and anterior abdominal wall edema. Plain abdominal X-ray showed multiple air-fluid levels with thickened bowel outline. A diagnosis of intestinal obstruction was made. The patient was fully resuscitated and planned for emergency exploratory laparotomy under general anesthesia. Intraoperative findings revealed a 360° clockwise rotation of the small bowel around the mesenteric pedicle of the superior mesenteric artery and vein including about 350 cm of bowel gangrene. Resection and anastomosis were done. The early postoperative period was uneventful. However, he had anastomotic dehiscence on the 5th postoperative day and had to be reoperated but sadly he died 24 h later due to complications of anesthesia. Nonspecific recurrent abdominal complaints in adults of any age should raise suspicion of the possibility of a midgut malrotation or malfixation with or without intermittent volvulus. This case highlights the importance of early diagnosis and treatment.

Keywords: Bowel gangrene, midgut malrotation, volvulus


How to cite this article:
Kache SA, Sale D, Yusuf N, Makama JG. Malrotation with midgut volvulus and bowel gangrene in a 45-year-old man. Arch Med Surg 2017;2:29-31

How to cite this URL:
Kache SA, Sale D, Yusuf N, Makama JG. Malrotation with midgut volvulus and bowel gangrene in a 45-year-old man. Arch Med Surg [serial online] 2017 [cited 2019 Jan 22];2:29-31. Available from: http://www.archms.org/text.asp?2017/2/1/29/214559




  Introduction Top


Midgut malrotation is generally regarded as a pediatric pathology with the majority of patients presenting in childhood.[1],[2],[3] The incidence has been considered to be approximately 1 in 500 live births.[4] It is believed that more than 90% of patients will present by the time of their first birthday,[5] with a majority of the complications occurring in the 1st month of life.[4],[6] Therefore, diagnosis is rare in adults with a reported incidence of 0.2%–0.5%,[1],[2],[3] which sometimes leads to delay in seeking healthcare and treatment.

Most adult diagnoses of midgut malrotation are made among asymptomatic patients; either on imaging investigations for unrelated conditions or at operations for other pathology.[2]

There is, however, a significant proportion of adults that have been affected who may present with acute or chronic symptoms of intestinal obstruction or intermittent and recurrent abdominal pain.

We present the case of a 45-year-old man with midgut volvulus and bowel gangrene resulting from malrotation.


  Case Report Top


Our patient is a 45-year-old man, who presented with sudden onset of colicky abdominal pain and abdominal swelling of 24 h duration. He had been having recurrent abdominal pain since childhood.

Physical examination revealed a patient in shock with markedly distended abdomen and anterior abdominal wall edema. Plain, erect abdominal X-ray film showed multiple air fluid levels while the supine film showed dilated loops of bowel [Figure 1].
Figure 1: Plane abdominal X-ray (a) erect and (b) supine showing multiple air-fluid levels (thin arrows) and thickened bowel wall (thick arrow)

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He was fully resuscitated and worked up for surgery. He had an emergency exploratory laparotomy under general anesthesia. Intraoperative findings revealed a 360° clockwise rotation of the small bowel around the mesenteric pedicle of the superior mesenteric artery and vein complicated by bowel gangrene of about 350 cm [Figure 2]. Resection and end to end jejunoileal anastomosis was done, with only about 130 cm of proximal small bowel left and 4 cm of terminal ileum. The immediate postoperative period was uneventful. However, he had anastomotic dehiscence on the 5th postoperative day and had to be reoperated intraoperative findings were that of anastomotic leak with marked dilated and thickened small bowel loops proximal to the anastomotic line and a collapsed distal bowel. A jejunostomy was done. The patient did not fully recover from anesthesia and sadly, died 24 h later.
Figure 2: Showing twisted gangrenous bowel with paracolic herniation

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  Discussion and Review of Literature Top


Midgut malrotation is rare in adults. The index patient is the first adult case of midgut malrotation with volvulus in our practice. This is consistent with the reported low incidence of malrotation in adults which is approximately 0.2%–0.5%.[1],[2],[3]

This patient presented with features of acute intestinal obstruction, he, however, reported the previous history of abdominal symptoms from childhood. Clinical presentation of rotational abnormality of the gut in adults is usually different to that of pediatric patients. Two distinct patterns of adult presentations have been reported: Acute and chronic. The chronic presentation is more common in adults. This is characterized by intermittent crampy abdominal pain, bloating, nausea and vomiting over several months or years.[2],[7],[8],[9]

However, the patient may present for the first time acutely and may report a previous history of abdominal symptoms, as in the case of our patient. A high index of suspicion is therefore needed.

Abdominal X-ray done for our patient showed features of intestinal obstruction, however, preoperative diagnosis was not made in the patient because plain X-ray has low diagnostic yield.[2]

Other means of diagnosis of midgut malrotation include upper gastrointestinal (UGI) contrast study, Doppler ultrasound scan, computed tomography (CT) scan, magnetic resonance imaging scan, and mesenteric arteriography.[1],[9],[10] These were not done in our patient because of his acute presentation and financial constraints.

The reported gold standard for diagnosis of gut malrotation is a UGI contrast study, particularly in the pediatric age group.[1],[2],[7],[10],[11] This will generally show the duodenum and duodenojejunal flexure located to the right of the spine.

CT scan with or without UGI contrast study is increasingly used preferentially as it is now considered the investigation of choice; providing diagnostic accuracy of 80%.[2],[7],[9],[10]

Symptomatic midgut malrotation undoubtedly requires surgical intervention although the management of asymptomatic patients is more controversial.[2],[12]

Our patient had volvulus with bowel gangrene necessitating bowel resection and anastomosis, however, the standard operation for malrotation is Ladd's procedure.[2],[13] The patient sadly did not survive long enough for us to determine if he will have had further symptoms since we did not do the standard procedure.


  Conclusion Top


Midgut volvulus due to malrotation could occur in adults. It is often associated with a diagnostic dilemma and poor prognosis. A high index of suspicion is therefore required in patients of any age group with abdominal symptoms.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Disclosure

The abstract of this case report was presented at the Joint Panafrican Pediatric Surgical Association and Association of Pediatric Surgeons of Nigeria conference at Lagos in 2016.



 
  References Top

1.
Zengin A, Uçar BI, Düzgün SA, Bayhan Z, Zeren S, Yaylak F, et al. Adult midgut malrotation presented with acute bowel obstruction and ischemia. Int J Surg Case Rep 2016;22:5-7.  Back to cited text no. 1
    
2.
Emanuwa OF, Ayantunde AA, Davies TW. Midgut malrotation first presenting as acute bowel obstruction in adulthood: A case report and literature review. World J Emerg Surg 2011;6:22.  Back to cited text no. 2
    
3.
Palepu RP, Harmon CM, Goldberg SP, Clements RH. Intestinal malrotation discovered at the time of laparoscopic Roux-en-Y gastric bypass. J Gastrointest Surg 2007;11:898-902.  Back to cited text no. 3
    
4.
Torres AM, Ziegler MM. Malrotation of the intestine. World J Surg 1993;17:326-31.  Back to cited text no. 4
    
5.
von Flüe M, Herzog U, Ackermann C, Tondelli P, Harder F. Acute and chronic presentation of intestinal nonrotation in adults. Dis Colon Rectum 1994;37:192-8.  Back to cited text no. 5
    
6.
Matzke GM, Moir CR, Dozois EJ. Laparoscopic ladd procedure for adult malrotation of the midgut with cocoon deformity: Report of a case. J Laparoendosc Adv Surg Tech A 2003;13:327-9.  Back to cited text no. 6
    
7.
Dietz DW, Walsh RM, Grundfest-Broniatowski S, Lavery IC, Fazio VW, Vogt DP. Intestinal malrotation: A rare but important cause of bowel obstruction in adults. Dis Colon Rectum 2002;45:1381-6.  Back to cited text no. 7
    
8.
Fu T, Tong WD, He YJ, Wen YY, Luo DL, Liu BH. Surgical management of intestinal malrotation in adults. World J Surg 2007;31:1797-803.  Back to cited text no. 8
    
9.
Moldrem AW, Papaconstantinou H, Broker H, Megison S, Jeyarajah DR. Late presentation of intestinal malrotation: An argument for elective repair. World J Surg 2008;32:1426-31.  Back to cited text no. 9
    
10.
Pickhardt PJ, Bhalla S. Intestinal malrotation in adolescents and adults: Spectrum of clinical and imaging features. AJR Am J Roentgenol 2002;179:1429-35.  Back to cited text no. 10
    
11.
Kapfer SA, Rappold JF. Intestinal malrotation-not just the pediatric surgeon's problem. J Am Coll Surg 2004;199:628-35.  Back to cited text no. 11
    
12.
Choi M, Borenstein SH, Hornberger L, Langer JC. Heterotaxia syndrome: The role of screening for intestinal rotation abnormalities. Arch Dis Child 2005;90:813-5.  Back to cited text no. 12
    
13.
Ladd WE. Surgical diseases of the alimentary tract in infants. N Engl J Med 1936;215:705-8.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2]



 

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