Acute midgut volvulus with extensive small bowel necrosis in an adult secondary to intestinal malrotation with mobile cecum: a rare case report

Abstract

Intestinal malrotation is a rare congenital anomaly in adults caused by incomplete rotation and fixation of the midgut during embryological development. Adult presentation is uncommon and may remain undiagnosed until complications such as midgut volvulus occur, leading to bowel ischemia and necrosis. Prompt diagnosis and surgical intervention are crucial to prevent morbidity and mortality. We report the case of a 38-year-old adult presenting with acute severe abdominal pain, recurrent bilious vomiting, and progressive abdominal distension. Clinical examination suggested acute intestinal obstruction with evolving peritonitis. Contrast-enhanced computed tomography revealed abnormal bowel orientation with twisting of mesenteric vessels producing the whirlpool sign and features of bowel ischemia. Emergency exploratory laparotomy was performed. Intraoperative findings demonstrated intestinal malrotation with midgut volvulus, extensive distal small bowel gangrene, and associated mobile cecum with pelvic appendix. The patient underwent derotation of the volvulus, resection of nonviable bowel, primary ileoileal end-to-end anastomosis, proximal diversion ileostomy, and appendicectomy. Postoperatively, the patient recovered gradually with restoration of bowel function. Surgical site infection with serous discharge corresponding to Southampton grade III wound infection developed but was managed successfully, and the patient was discharged in stable condition. Adult intestinal malrotation presenting with acute midgut volvulus is a rare but life-threatening surgical emergency. Early radiological diagnosis, especially recognition of the whirlpool sign on computed tomography, and urgent surgical management are essential for favorable outcomes. Intestinal malrotation should be considered as a differential diagnosis in adults presenting with acute abdomen and intestinal obstruction.