intestinal malrotation is more commonly diagnosed in the neonatal period , while adult presentations are reported with an incidence of 0.2% .
such patients pose a unique challenge for the surgeon acutely both from a diagnostic and treatment standpoint . herein , we report and review a case of intestinal malrotation with midgut volvulus in an adult .
a 53-year - old man presented to the hospital with a 45 hour history of sudden onset , sharp right upper quadrant ( ruq ) pain that began postprandially .
he is otherwise healthy with a past medical history significant only for benign prostatic hypertrophy and no prior abdominal surgeries .
he denies any recent trauma , weight loss , travel history , changes in appetite or bowel habits .
his abdomen was diffusely tender with the point of maximal tenderness in the right and left upper quadrants .
his hematological investigations revealed an elevated white blood cell count of 11.6  10/l with a normal lactate of 0.8 mmol / l .
computerized tomography scan of the abdomen demonstrated evidence of small bowel malrotation with volvulus causing closed - loop obstruction .
the radiologist reported on mucosal hypo - enhacement concerning for small bowel ischemia ( fig .
1 ) . there was no evidence of pneumatosis intestinalis , or free air in the abdomen .
his initial management consisted of intravenous ( iv ) fluids , iv antibiotics and a nasogastric tube .
computerized tomography scan of the abdomen in axial view demonstrating small bowel volvulus . upon entry into the abdomen ,
there were numerous adhesions causing closed - loop internal hernias at multiple locations along the small bowel .
a mass like object was seen in the ruq , which initially appeared to be colon .
we proceeded with lysis of adhesions and it became evident that this mass was small bowel .
in addition , with further dissection , the small bowel was found to segregate in toto to the right abdomen , consistent with malrotation .
the mid - portion of the small bowel had rotated along its mesentery demonstrating midgut volvulus .
subsequently , we performed a counter - clockwise detorsion of the small bowel , internal hernia reduction and take down of ladd s band in the ruq .
following adhesiolysis and detorsion , the cecum and appendix were seen in the left lower quadrant , and an appendectomy was also performed .
the affected small bowel segment was re - examined and deemed viable , avoiding a resection .
the patient s abdomen was closed primarily and he was transferred to the surgical floor .
the patient s postoperative course was marked by prolonged ileus requiring 24 hours of total parental nutrition .
malrotation occurs when normal embryonic rotation and fixation of small bowel fail to occur during the 1012th week of gestation [ 24 ] .
consequently , a narrow mesenteric base and ladd s band ( adhesion running from cecum to the right lateral abdominal wall ) are formed predisposing patients to obstruction .
thus , volvulus most commonly presents as a surgical emergency during the neonatal period or first month of life , and less commonly in older children and adults [ 1 , 2 ] .
intestinal malrotation in adults tend to have a variable clinical presentation ranging from acute bowel obstruction to insidious , nonspecific symptoms , which often delays diagnosis compared to pediatric patients [ 2 , 5 ] .
most adults present with chronic symptoms which may be present for greater than 6 months . patients may complain of intermittent abdominal pain , bloating and vomiting , frequently in the postprandial period .
conversely , ~1015% of adults with malrotation present with acute volvulus complaining of severe abdominal pain , nausea , vomiting , hematemesis or hematochezia , with or without hemodynamic instability [ 5 , 6 ] . in this current report , the patient reported mild abdominal pain and denied other chronic symptoms , and presented acutely with obstruction secondary to volvulus .
patients experiencing chronic symptoms without acute volvulus are treated with an elective ladd s procedure .
the ladd s procedure , originally described by pediatric general surgeon william ladd in 1936 , remains the mainstay in surgical management .
the procedure involves five steps and has been described both via an open or laparoscopic approach : assessment for volvulus with counter - clockwise detorsion if present , ladd s band division , inter - mesenteric band division ( fibrous bands between bowel loops other than cecum and duodenum ) , appendectomy due to its aberrant location ( and prevention of future confusion ) and finally placement of bowel in the corrected anatomic position .
if frank gangrene is evident , the involved bowel is resected ; if viability is equivocal , relook laparotomy is recommended within 2448 hours . in patients presenting with incidental malrotation ,
the decision to proceed with operative intervention versus conservative management is controversial . due to the rarity of the condition , only small case series are available and largely in the pediatric literature .
however , most authors advocate for surgical intervention due to the lack of reliable predictors for the development of midgut volvulus .
the outcome of adults undergoing operative intervention for malrotation depends on the severity of presentation [ 5 , 7 ] .
the mortality rate ranges from 0 to 25% , with acute volvulus having the highest mortality .
patients may also experience significant morbidity postoperatively ( up to 60% ) [ 1 , 5 ] .
prolonged ileus is anticipated following ladd s procedure , as was evident in our patient .
recurrent volvulus occurs in 1.88% of cases , and clinicians should be aware of its possibility . in conclusion , we present a rare case of malrotation with midgut volvulus in an adult . given his acute presentation , operative intervention was the natural trajectory in his management .
however , this entity can be challenging to diagnose in the adult population and a high index of suspicion would facilitate a timely diagnosis .
 abstractwe report a case of a 53-year - old male who presented with acute onset right upper quadrant ( ruq ) abdominal pain with investigations demonstrating malrotation causing midgut volvulus and subsequent intestinal obstruction . 
 the patient was consented for an emergent operation and underwent an exploratory laparotomy . 
 operative findings included the presence of adhesive bands in the ruq ( ladd s band ) , volvulus of the mid - portion of the small bowel in a clockwise fashion and multiple intra - abdominal adhesions causing internal hernias . 
 we subsequently performed a ladd s procedure and the patient had an uneventful recovery with eventual discharge on postoperative day 8 . 
 this case report reviews the incidence of malrotation in adults . 
 it also highlights the difficulty in diagnosing midgut volvulus in the adult population given the nonspecific , insidious symptoms therefore prompting awareness of its existence and a high degree of clinical suspicion . 
INTRODUCTION
CASE REPORT
DISCUSSION