Search

Background/Purpose Oesophageal Atresia (OA) is associated with co-existent anomalies. There is a controversy of literature pertaining to the risk (s) of intestinal malrotation. In order to guide management we critically evaluate the incidence of IM anomalies in OA newborns. Design MEDLINE and EMBASE databases were searched using keywords "(O)Esophageal Atresia and Malrotation/Associated Abnormalities/Associated Anomalies". Full texts of articles were screened if manuscripts exclusively reported patients with OA malrotation and/or associated anomalies. Larger case series (> 10patients) were included if abstract (s) showed that associated anomalies were systematically assessed. Full eligibility criteria required at least one case of malrotation in an OA index case. Data were collected on article type, number of patients and method (s) of diagnosis. Results 632 abstracts were screened of which 158 papers were analysed based on inclusion criteria-30 manuscripts documented the incidence (%) of malrotation. Incidence rate (s) were 0.5-13%. Malrotation was observed to have a higher incidence (10-44%) in OA babies with other gastrointestinal anomalies (VACTERL). Conclusion Newborns with OA appear to be at a higher risk (%) of having intestinal malrotation anomalies than healthy babies. Prospective studies are required to accurately quantify and define the ' true incidence ' of this association. Given the potential lethal consequences of midgut volvulus screening may be justified in OA babies. Consensus guidelines (DELPHI) exploring surgeons attitudes with regards management of ' asymptomatic malrotation ' disorders in OA newborns may further guide best practice.

Introduction Acute appendicitis is one of the most frequent intra-abdominal diseases requiring emergency surgical consult and treatment. The diagnosis of this condition is based on clinical features and radiologic findings. One-third of patients with acute appendicitis present unusual symptoms. There are several circumstances that may cause misdiagnosis and unclear prognostic prediction. Among these, situs viscerum inversus totalis and midgut malrotation can be challenging scenarios, leading to a delay in treatment, especially when these conditions are unknown. We decided to carry on a systematic review of published cases of acute appendicitis in the context of anatomical anomalies. Methods We used the MESH terms “appendicitis” AND “situs inversus” AND/OR “gut malrotation” to search for titles and abstracts. Inclusion criteria were patients with clinical and/or radiological diagnosis of acute appendicitis, with conservative or surgical management and with preoperative/intraoperative findings of situs viscerum inversus or gut malrotation. Additionally, previous reviews were examined. Exclusion criteria of the studies were insufficient patient clinical and demographic data. Results We included in this review 70 articles concerning 73 cases of acute appendicitis with anatomical anomaly. Patients were aged from 8 to 86 years (median: 27.0 years). 50 were male and 23 were female. 46 patients (63%) had situs viscerum inversus, 24 (33%) had midgut malrotation, 2 (2.7%) had Kartagener’s syndrome, one of them (1.4%) had an undetermined anomaly In 61 patients the anatomical anomaly was unknown previously (83.6%), while 16,4% already were aware of their condition. Conclusion Acute appendicitis can occur in association of rare anatomical anomalies and in these cases diagnosis can be challenging. Situs viscerum inversus and midgut malrotation should always be considered in the differential diagnosis of a patient with left lower quadrant pain, especially in younger population. Besides clinical features, it is fundamental to implement the diagnostic progress with radiological examination. Laparoscopic approach is useful to identify and treat acute surgical emergency and it is also a diagnostic tool and can be tailored in order to offer the best exposition of the operatory field for each single case.

Left-sided abdominal pain is an uncommon presentation of acute appendicitis. When a patient presents with this complaint, appendicitis can be difficult to diagnose, thus resulting in delayed definitive therapy and increased morbidity and mortality. In this report we discuss the case of a middle-aged man, who presented with left-sided abdominal pain, and was diagnosed to be suffering from acute appendicitis along with asymptomatic midgut malrotation.

Kabuki syndrome (KS) is a rare heterogeneous phenotypic genetic syndrome, characterized by hypotonia, developmental delay and/or intellectual disability with typical facial features. It is challenging to diagnose KS in newborn and young infant. We report a Thai girl who presented with two rare co-occurrence phenotypes, hyperinsulinemic hypoglycemia and midgut malrotation. She had not have distinctive facial dysmorphism during neonatal period. At 4 months of age, she had poor weight gain with some facial features suggestive KS. Singleton whole exome sequencing (WES) was carried out followed by Sanger sequencing of the supposed variant. The result indicated a novel de novo heterozygous KMT2D mutation, c.15364A>T (p.Lys5122*), confirming KS. Our patient revealed rare clinical manifestations from the diverse population and address the benefit of WES in establishing early diagnosis of KS before typical facial gestalt exhibited, which allows timely and appropriate management to maximize developmental achievement.

Background: Intestinal malrotation refers to the partial or complete failure of rotation of midgut around the superior mesenteric vessels in embryonic life. Arrested midgut rotation results due to narrow-based mesentery and increases the risk of twisting midgut and subsequent obstruction and necrosis. Midgut volvulus secondary to intestinal malrotation is a rare presentation in adults more so in the elderly. Its rarity portends a diagnostic dilemma for both the surgeon and radiologist, and CT scan showed dilated large and small intestine segments with air-fluid levels and twisted mesentery around superior mesenteric artery and vein indicating "whirlpool sign". In our patient Case presentation: 42 years old male who presented to the emergency department with acute onset of pain in the RUQ, vomiting, and absolute obstipation for the last 2 days. This patient had a history of similar two episodes of sub-acute intestinal obstruction in the last 6 months which has been managed conservatively. The patient underwent an elective exploratory laparotomy after 2 days of failed conservative management. 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 intraabdominal adhesions and empty RIF and caecum pulled up in RUQ. We subsequently performed a Ladd's procedure, multiple adhesiolysis, and caecopexy and the patient had an uneventful recovery with eventual discharge on postoperative day 12. This case report reviews the incidence of malrotation in adults. It also high Conclusion: lights 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. Malrotation should be considered in the differential diagnosis in patients presented with acute abdomen and intestinal ischemia.

Aim Fetal bowel dilatation (FBD) in the late trimester of pregnancy can be related with varies of prognosis. Our aims were to obtain antenatal factors that might have relevance for the distinct prognosis with FBD. Methods Seven features of 68 pregnancies presented with FBD were assessed. The best cut-off value to predict intestinal outcomes was selected using receiver-operating characteristics curves, and the effective variables were included into a logistic regression model. Results The best cut-off valves to predict intestinal pathologies were 14.5 mm of fetus dilated loop and 37.7 weeks of gestational age at delivery, respectively. The congenital gastrointestinal tract anomalies included 24 cases (92.3%) of intestine atresia, 1 case (3.85%) of small intestine volvulus and 1 case (3.85%) of midgut malrotation. Conclusion Fetal dilated loops and gestational age at delivery are both an independent risk factor for predicting intestinal pathologies of newborns, which should arouse high attention.

Associated midgut malrotation and colon cancer in adult patients is extremely rare and associated with delayed diagnosis and increased morbidity. We present the case of a patient with a three-week history of weakness, diarrhea, and abdominal pain with invagination of the distal ileum. Exploratory laparotomy with ileocecal resection revealed invagination, malrotation, and cecal adenocarcinoma.

Midgut malrotation is a congenital condition resulting from incomplete normal intestinal rotation after physiologic gut herniation. While it can remain asymptomatic over an entire lifetime, midgut volvulus is most likely to occur during early life. While an upper gastrointestinal series is the imaging modality of choice for definitive diagnosis, sonography is a safe and effective modality capable of indicating midgut malrotation, especially in pediatric patients. This case study illustrates the sonographic findings associated with intestinal malrotation with volvulus and discusses the etiology, signs, symptoms, and treatment of the condition. In addition, the sonographic findings are correlated with upper gastrointestinal results, which confirmed midgut malrotation. The diagnosis of volvulus secondary to midgut malrotation was confirmed by a laparoscopic Ladd procedure performed to treat the neonate.

Introduction and importance Midgut Malrotation (MM) is a potentially fatal and rare congenital anomaly that results from an incomplete rotation of the bowel 270 degrees around the Superior Mesenteric Axis. Newborns are the most affected age group, nevertheless, adult malrotation can manifest, but in a much rarer incidence rate. Clinical awareness must be present when faced with a surgical abdomen in an adolescent patient because this pathology can have several misleading signs and symptoms which may eclipse the true preoperative diagnosis and masquerade as another, and this could result in implementing a different therapeutic approach. Swift clinical informed judgments must be made and acted upon to limit the morbidity and mortality resultant from this pathology. Case presentation We present the case of a 15-year-old female, who was brought to our Emergency Department (ED) with a 5-day-history of biliary emesis which evolved into obstipation with continuous and excruciating abdominal pain. Computed Tomography (CT) scan indicated gastric and duodenal dilation in addition to a “Whirlpool sign”. Exploratory laparotomy was done, and a Ladd's procedure was performed. Clinical discussion We treated our patient by performing Ladd's procedure and adhesiolysis. Diagnosis is conventionally established pre-/intraoperatively based on radiological imaging and clinical suspicion. Therapeutic methods for this pathology are primarily surgical in nature. Conclusion Midgut Malrotation is a rare entity, thus, it is crucial to further study this type of clinical presentation and keep it in mind to be able to make an accurate diagnosis to reach the optimal outcome for patients who present with acute surgical abdomen., Highlights • MM is a potentially fatal and rare congenital anomaly of the Gastrointestinal tract comprising 0.2% of live births. • Most cases are diagnosed within the first year of neonatal life. Rarely, a case is diagnosed in the adolescent population. • Symptoms are non-specific and this warrants high clinical suspicion when presented with a case of acute surgical abdomen. • There are three major types of Midgut Malrotation according to the established Stringer classification. • Surgery is the mainstream treatment modality and Ladd's procedure and remains the gold standard for treatment of MM.

Malrotation of the midgut is generally considered as a pediatric pathology with the majority of patients presenting in childhood. The diagnosis is rare in adults, which sometimes leads to delay in diagnosis and treatment. An index of suspicion is therefore required when dealing with patients of any age group with abdominal symptoms. We present a case of a 26-year-old male who presented with left lower abdominal pain with preoperative computed tomography showing suspected left-sided appendicitis associated with midgut malrotation. The duodenum, small bowel, and cecum were abnormally located, with the presence of a thickened and inflamed appendix with fecalith images. The patient underwent an emergency laparotomy, and ruptured cecal diverticulitis with abscess formation was confirmed. We performed a cecectomy, and the patient did not have an uneventful postoperative recovery. A review of the literature is presented to highlight the rarity of midgut malrotation and the controversies surrounding its surgical management in the adult population with ruptured left-sided cecal diverticulitis.

Introduction: Colorectal cancer is one of the most common types of malignant tumors worldwide. In patients with situs abnormalities such as situs inversus totalis or situs ambiguus, the presence of this tumor could be a challenge for the surgeon, especially in cases in which the laparoscopic approach is considered. Case presentation: We report the case of a 69-year-old male patient with situs inversus totalis. This particular case of situs inversus totalis was not a classical type because the patient had bilateral bilobed lungs, polysplenia, preduodenal portal vein in association with midgut malrotation. The pathology report after surgery revealed moderately differentiated adenocarcinoma of the sigmoid colon, stage pT3 N1c M1a, liver metastases but without metastases in the eight resected lymph nodes. We compared this rare association of diseases of particular anatomic aspects with other reports in the specialty literature. Conclusion: The identification of situs abnormalities or other malformations in patients with resectable colorectal cancer is essential, thus preoperative imaging studies are imperative for a proper surgical management. Colorectal cancer metastasizing patterns in patients with intestinal malrotation need to be further investigated.

Midgut malrotation is a congenital anomaly in the embryological development of the foetal intestinal rotation. It has been estimated that it affects approximately 1 in 500 live births . However, the true incidence is difficult to determine as a substantial number of cases will go undetected throughout life. The vast majority of the complications associated with midgut malrotation present in the first month of life and 60-85% of cases are diagnosed in this age group . It is reported that more than 90% of patients will present by the time of their first birthday . Adult midgut malrotation is very rare and its incidence has been reported to be between 0.0001% and 0.19% . Most adult diagnoses of midgut malrotation are made in asymptomatic patients; either on imaging investigations for unrelated conditions or at operations for other pathology. This scenario of incidental diagnosis is becoming increasingly common, particularly with improvements, and increased use, of diagnostic imaging techniques in modern practice. However, there are a small proportion of affected adults who may present with acute or chronic symptoms of intestinal obstruction or intermittent and recurrent abdominal pain. The true diagnosis in this age group is fraught with immense difficulty, especially because the typical presentation is with non-specific symptoms and the fact that in adults, Surgeons usually have low index of suspicion and may not consider the diagnosis a possibility in the initial evaluation of adult patients with abdominal pain.

Highlights • Abdominal pain due to acute appendicitis in one of the most causes of access to Emergency Room requiring surgical consult and treatment. • The occurrence of anatomical anomalies should be considered especially when clinical and imaging features are misleading. In these cases laparoscopic surgery can be a safe tool in order to confirm uncertain diagnosis. • We report a case of acute appendicitis in a 23-year-old Caucasian men with situs viscerum inversus detected on radiological investigation. • Laparoscopic approach was used to confirm the diagnosis and to perform appendectomy. Trocars placement was tailored for this peculiar case. • Situs viscerum inversus and midgut malrotation should be taken into consideration in patients with findings of the physical examination suspicious for left-sided acute appendicitis., Introduction Abdominal pain due to acute appendicitis in one of the most causes of access to Emergency Room requiring surgical consult and treatment. The occurrence of anatomical anomalies should be considered especially when clinical and imaging features are misleading. In these cases laparoscopic surgery can be a safe tool in order to confirm uncertain diagnosis. Case report We report a case of acute appendicitis in a 23-year-old Caucasian men with situs viscerum inversus detected on radiological investigation. Laparoscopic approach was used to confirm the diagnosis and to perform appendectomy. Trocars placement was tailored for this peculiar case. Discussion One third of patient with acute appendicitis complains abdominal pain in an unexpected location due to various anatomical position of appendix. Left-sided acute appendicitis is a cause of misdiagnosis and it can occur in association with anatomical anomalies such as situs viscerum inversus and midgut malrotation. Laparoscopic surgery may represent a valuable approach in terms of differential diagnosis and treatment in these patients. Conclusion Left-sided acute appendicitis should always be considered in young male patients with left lower quadrant pain. Laparoscopic approach is useful and safe procedure both for diagnosis and treatment of these unclear clinical pictures.

Main teaching point: Right paraduodenal hernia typically occurs in the fossa of Waldeyer, with the herniated bowel sac located posterior to the right colic artery and vein.

Right paraduodenal internal hernia, which has an embryonic origin, can be a rare cause of bowel obstruction, generally in young adults. We report the case of a young man who sought emergency care for acute abdominal pain with obstruction.

Midgut malrotation is a congenital anomaly seen usually in childhood. Its presentation as an acute intestinal obstruction is extremely rare in adults usually identified intra operatively. A high index of suspicion is always required when dealing with any case of acute intestinal obstruction. We report a case of young adult who presented with symptoms of acute intestinal obstruction and was diagnosed intra-operatively as cecal volvulus with impending perforation caused by midgut malrotation. Malrotation of the intestinal tract is seen due to aberrant embryology. The presentation of intestinal malrotation in adults is very rare. Contrast enhanced Computed tomography (CT) can show the abnormal anatomy clearly. Anomalies like midgut malrotation can present as an operative dilemma and awareness regarding these conditions can help surgeons deal with these conditions.

Highlights • Midgut volvulus is usually diagnosed in first weeks of life, or even, in many cases, before birth. • Incidence of midgut malrotation among pediatrics is 1 in 500 livebirths. • Incidence of adult midgut malrotation is reported between 0.0001% and 0.19%. • This is case rare presentation in which a 34 year old man was presented. With diagnosis of midgut volvulus underwent laparotomy., Introduction The incidence of midgut vovulus is rare in adults. However, a significant number of cases were seen in infant and children. Presentation of case We report a case of a 34-year-old male who presented to the emergency room with persistent periumbilical abdominal pain without any other symptoms. Contrast-enhanced CT showed clearly the typical finding of midgut volvulus like whirlpool sign, corkscrew sign, and the superior mesenteric vein to the left of superior mesenteric artery. The patient was planned for Ladd’s procedure and emergency laparotomy performed successfully with an uneventful postoperative recovery. Discussion Managing midgut volvulus is based on presentation. In symptomatic cases surgery is the treatment, but in asymptomatic cases, treatment is controversial. Conclusion Although midgut volvulus is rare in adults, it should be considered as an intestinal obstruction.

Altinay-Kirli E, Ozcan R, Oncul M, Ozmen E, Elicevik M, Buyukunal C, Emir H, Topuzlu-Tekant G. A rare cause of abdominal pain: Ectopic ovary and intestinal malrotation. Turk J Pediatr 2017; 59: 699-703. Ectopic ovary is a rare anomaly that can be associated with unicornuate uterus and renal anomalies. Intestinal rotational anomalies are failure of normal rotation and this arrest in development can predispose to develop a malfixated midgut that is a risk factor for volvulus and significant morbidity and mortality especially in early childhood. Cyclic abdominal pain is a common symptom for both of two distinct pathologies in adolescent ages. Here, we report a case of unicornuate uterus together with right ectopic ovary and intestinal malrotation.

Akut apandisit, acil cerrahi gerektiren en yaygın akut karın ağrısı nedenlerinden biridir. Apendiksin varyasyonel anatomik lokalizasyonlarından dolayı olguların yaklaşık üçte birinde farklı bir kadranda ağrı olabilir. Akut apandisit, sitüs inversus totalis (SIT), Midgut malrotasyon (MM) gibi birkaç doğuştan anomali dışında sol alt kadran ağrısında nadiren akla gelir. Midgut malrotasyon nadir bir doğuştan anomali olup superior mezenterik damarların etrafında rotasyon veya bağırsakların fiksasyonu hatasından kaynaklanır ve bağırsağın inkomplet rotasyonu veya nonrotasyonu anlamına gelir. Burada sol alt kadran ağrısı ile başvuran ve akut perfore apandisit tanısı alan intestinal nonrotasyonlu bir olgu sunuldu. Klinisyenler intestinal nonrotasyonun sol alt kadran ağrısı ile prezente olan akut apandisit ile komplike olabileceğini bilmeli, sol alt kadran lokalizasyonlu apandisitlerde intestinal nonrotasyon akla gelmelidir. Akut apandisit, acil cerrahi gerektiren en yaygın akut karın ağrısı nedenlerinden biridir. Apendiksin varyasyonel anatomik lokalizasyonlarından dolayı olguların yaklaşık üçte birinde farklı bir kadranda ağrı olabilir. Akut apandisit, sitüs inversus totalis (SIT), Midgut malrotasyon (MM) gibi birkaç doğuştan anomali dışında sol alt kadran ağrısında nadiren akla gelir. Midgut malrotasyon nadir bir doğuştan anomali olup superior mezenterik damarların etrafında rotasyon veya bağırsakların fiksasyonu hatasından kaynaklanır ve bağırsağın inkomplet rotasyonu veya nonrotasyonu anlamına gelir. Burada sol alt kadran ağrısı ile başvuran ve akut perfore apandisit tanısı alan intestinal nonrotasyonlu bir olgu sunuldu. Klinisyenler intestinal nonrotasyonun sol alt kadran ağrısı ile prezente olan akut apandisit ile komplike olabileceğini bilmeli, sol alt kadran lokalizasyonlu apandisitlerde intestinal nonrotasyon akla gelmelidir.

Left sided appendicitis is a rare pathology. Two situations may explain the occurrence of the disease: situs inversus or midgut malrotation. Its diagnosis is based on clinical presentation but confirmed by radiological examination. Our observation is based on a left-sided acute appendicitis with a midgut malrotation in a 31-year-old patient with no clinical history.

Intestinal Malrotation in adults is twisting of the intestines that lead to mal positioning of the bowels and malfixation of the mesentery, blocking the digestive tract and preventing the proper passage of food. Midgut malrotation is a congenital anomaly in the embryological development of the foetal intestinal rotation. It has been estimated that it affects approximately 1 in 500 l ive births . [ 1 ] Symptomatic malrotation is estimated to occur in 1 in 6000 live births . [ 2 ] Traditionally, intestinal malrotation has been considered primarily a disease of infancy with infrequent occurrence beyond the first year of life. Adult midgut malrotation is very rare and its incidence has been reported to be between 0. 0001% and 0. 19% . [ 3 , 4 ] Most adult diagnoses of midgut malrotation are made in asymptomatic patients; either on imaging investigations for unrelated conditions or at operations for other pathology. However, there are a small proportion of affected adults who may present with acu te or chronic symptoms of intestinal obstruction or intermittent and recurrent abdominal pain. The true diagnosis in this age group is fraught with immense difficulty, especially because the typical presentation is with non - specific symptoms and the fact t hat adult Surgeons usually have low index of suspicion and may not consider the diagnosis a possibility in the initial evaluation of adult patients with abdominal pain. We report a rare case of an 36 year old patient presented as acute intestinal obstruct ion due to midgut malrotation

We present a case of 14-year girl with left-sided acute appendicitis who presented with lower abdominal pain. Midgut malrotation occurs at a rate of 1 in 500 live births. The condition is incidentally diagnosed during various radiological investigations done for other purposes. However, such patients may present with conditions like acute appendicitis, which poses a diagnostic dilemma if a high index of suspicion is not kept. The purpose of this case report is to increase awareness in the emergency physicians and young surgeons of this rare presentation; and the importance of radiological investigations in the diagnosis of left-sided appendicitis, to decrease morbidity and mortality.

Left paraduodenal hernias are congenital internal hernias caused by the failure of the mesenteric and parietal peritoneum fusion with midgut malrotation. We present a case of a 22-year-old woman who presented with acute abdominal pain and was found to have a left paraduodenal hernia on CT. She underwent a laparoscopic reduction and primary repair of the defect. She presented two weeks later with acute abdominal pain and emesis and was taken emergently to the operating room after a CT showed a high-grade obstruction at the site of the prior hernia defect. In a laparoscopic converted to open exploration, several of the prior hernia closure’s sutures were removed and the bowel was released. This case highlights the importance of a perfect hernia closure, tight enough to prevent a recurrence but not too tight to cause an obstruction.

Highlights • Midgut malrotation in adulthood is rare, with reported incidence 0.1–0.5%. • Acute appendicitis with undiagnosed midgut malrotation has been sparsely described. • Presenting symptoms are often atypical which delay diagnosis. • Early recognition with appropriate imaging is key to diagnosis and appropriate management., Introduction Acute appendicitis in the setting of midgut malrotation is uncommon. Midgut malrotation commonly presents within the first month of life. A minority remain asymptomatic and may present with concomitant abdominal pathology making diagnosis difficult. Presentation of case This paper reports a rare case of a 73-year-old male diagnosed with acute appendicitis and asymptomatic MM .The patient underwent a laparoscopic appendectomy, but had an unplanned return to theatre for washout of post-operative intra-abdominal haematoma. Discussion Midgut malrotation is commonly described by the stringer classification and type 1a is the most common in adults. There have only been a handful of documented cases of acute appendicitis with midgut malrotation occurring in the adult population. Previous delay in diagnosis has led to a delay in definitive management. Both laparoscopic and open surgery has been used in the past. Conclusion Acute appendicitis with malrotation should be considered in elderly patients presenting with atypical signs and symptoms. Imaging offers significant advantage for timely and definitive management.

INTRODUCTIONMidgut malrotation is a congenital anomaly presenting mainly in the childhood. Its presentation as an acute intestinal obstruction is extremely rare in adults usually recognized intra-operatively, therefore a high index of suspicion is always required when dealing with any case of acute intestinal obstruction.PRESENTATION OF CASEWe report two cases of young adults who presented with symptoms of acute intestinal obstruction and were diagnosed intra-operatively as cecal volvulus and paraduodenal hernia, respectively, caused by midgut malrotation. Post-operative CT scan confirmed these findings.DISCUSSIONMalrotation of the intestinal tract is a product of an aberrant embryology. The presentation of intestinal malrotation in adults is rare (0.2–0.5%). Contrast enhanced CT can show the abnormal anatomic location of a right sided small bowel, a left-sided colon and an abnormal relationship of the superior mesenteric vein (SMV) situated to the left of the superior mesenteric artery (SMA) instead of to the right.CONCLUSIONAnomalies like midgut malrotation can present as an operative surprise and awareness regarding these anomalies can help surgeons deal with these conditions.

Midgut malrotation is a rare anatomic anomaly that complicates the diagnosis and management of acute abdominal pain. It is a congenital anomaly that arises from incomplete rotation or abnormal position of the midgut during embryonic development. A two years old boy was brought with recurrent abdominal pain and vomiting. On ultrasonography, the intestinal malrotation was suspected and thus contrast enhanced computed tomography (CECT) was done. On CECT, abnormal relationship between the superior mesenteric artery (SMA) and superior mesenteric vein (SMV), colon on the left side of the abdominal cavity, 'Whirlpool sign' etc., were found. All findings were suggestive of midgut malrotation with volvulus. Detection of uncomplicated malrotation should not be trivialized because such patients might experience a future complication.

Background: A review of the English literature from 1980 to 2010 revealed only six gravidas managed by total parenteral nutrition (TPN) for at least 16 weeks of pregnancy. We found only two gravidas with obstruction due to malrotation, both managed surgically. Case: We report a unique case of bowel obstruction presenting in the second trimester due to congenital malrotation of the small intestine that was conservatively managed by prolonged TPN, with the delivery of a healthy term baby girl. Surgical correction was delayed until the patient was not pregnant. Conclusion: Intestinal obstruction in pregnancy is rare, and malrotation of the small bowel as the cause is extremely rare. This is the first case of intestinal obstruction in midtrimester in which prolonged TPN was employed when surgery was contraindicated. TPN may be considered if surgery cannot be performed, with an excellent outcome likely.

Provoked seizures are a common pediatric problem and can be caused by multiple etiologies. However, there have been few reports of benign infantile seizures associated with gastrointestinal tract abnormality. We report on a 3-month-old male infant who presented with multiple afebrile seizures, EEG abnormalities and a midgut malrotation. Surgical treatment of the malrotation resulted in seizure resolution and EEG normalization. This case emphasizes that patients presenting with multiple seizures and symptoms of gastroenteritis should be evaluated for abnormalities of the gastrointestinal tract.

Small bowel malrotation is a congenital disorder of midgut rotation usually encountered in paediatric age group. Here is a case report of small bowel sub-acute obstruction due to midgut volvulus precipitated by malrotation. The incidence of microtonal presentation in adults is 0.2%, making this case a rarity. This patient presented with chronic vague symptoms like dyspepsia, diffuse low-grade abdominal pain, non-projectile vomiting which were on and off for 4 to 5 years since he presented to us. Furthermore because of the remitting nature of his symptoms, these symptoms usually pointed out to a more benign ailment, so unless we do a more elaborate study like computed tomography, we might miss the diagnosis. This case report emphasis the wide range of presenting age for certain congenital disorders like malrotation of gut.

Midgut malrotation is typically presented during the first few months of life but sometimes may encounter later in life, causing difficulties and mistakes in diagnosis. We reviewed records of eleven rare patients with midgut malrotation older than one year of age and extracted their clinical and paraclinical data. The most common presenting symptoms were bilious vomiting, recurrent abdominal pain and constipation. Five of eleven patients had presented from neonatal period. The average interval between first symptoms and surgical correction of malrotation was about 22 months. Some of the patients had been undergone false treatments. Most cases were diagnosed by contrast studies (upper gastrointestinal series and barium enema). Diagnosing midgut malrotation in older children is often delayed. This anomaly should be suspected in all children with signs and symptoms of small bowel obstruction, chronic abdominal pain and vague abdominal discomfort and in all patients of any age with abdominal discomfort who do not respond to other therapies. Contrast studies may be necessary to rule out malrotation in suspected patients.

w p T l t T Intestinal malrotation is a surgical disease affecting priarily the pediatric population, with an incidence of aproximately 1 in 6000 live births. It affects adults only arely, usually occurring in asymptomatic persons at the ime of another operation or as an incidental finding on adiologic examination [1,2]. We report one such patient, a 4-year-old man found to have midgut malrotation while ndergoing robotic-assisted laparoscopic Roux-en-Y gastric ypass (RLGBP) for morbid obesity.

An infant presented with clinical signs and symptoms suggestive of a pyloric stenosis. On abdominal ultrasound, pyloric stenosis was excluded, and other causes for proximal duodenal obstruction, such as a duodenal web or annular pancreas, were suspected. At surgery, the cause was found to be due to an anterior portal vein or preduodenal portal vein, compressing the duodenum. There were no associated findings such as midgut malrotation, duodenal web and congenital anomalies. The treatment was a diamond-shaped duodeno-duodenostomy anterior to the portal vein. The patient improved after surgery.

Malrotation of the midgut is mainly a childhood congenital anomaly. Adult Midgut malrotation is rare with the clinical symptomatology varied and non-specific making pre-operative diagnosis difficult. Midgut volvulus from malrotation is a true surgical emergency requiring early intervention to prevent bowel necrosis and death.We report a 27yr old male who was referred to our centre with paralytic ileus post appendectomy. He underwent emergency laparotomy with findings of gangrenous volvulus involving almost the entire midgut from malrotation. He had bowel resection with jejunocolic anastomosis. Post-operatively he was referred on account of short bowel.A high index of suspicion is needed in acute abdomen with atypical features to allow for early diagnosis and prompt intervention to avert this catastrophic event.

Midgut malrotation is a congenital anomaly of intestinal rotation and fixation that is generally seen in neonatal population. Adult cases are rarely reported. Early diagnosis is crucial to avoid life threatening complications. Here, we present an adulthood case of midgut volvulus as a rare cause of acute abdomen.

“Always look for duodenal obstruction in a case of malrotation”, this dictum has to be followed. The patient was operated for midgut malrotation at day 2 of life followed by foreign body removal by upper gastrointestinal endoscopy at 2 years of age. We report atwo and half year male child with Down′s syndrome who presented to us with history suggestive of recurrent upper gastrointestinal tract obstruction. During surgery a post sphincteric duodenum web was confirmed and foreign body (berry seed) which had impacted proximal to it was removed. The web was excised and the duodenum, split longitudinally, sutured transversely. The postoperative course was uneventful and patient is asymptomatic at follow up. This case illustrates that diagnosis was delayed for 2΍ years after initial presentation in early neonatal age. (Dig Endosc 2013;4(1):10–12)

Midgut malrotation includes a range of developmental abnormalities that occur during fetal intestinal rotation. Manifestations of intestinal malrotation are generally seen in the paediatric population and are uncommon in adults. Symptomatic patients may present with either acute abdominal pain due to midgut volvulus, or chronic abdominal pain due to proximal midgut partial obstruction in the presence of congenital bands. A limited number of paediatric cases of duodenal occlusion due to duodenal malrotation has been previously reported in the medical literature. We herein report the case of a 57-year-old woman who presented with duodenal obstruction due to organoaxial partial rotation of the distal duodenum associated with midgut malrotation. This is probably the first of such a case diagnosed in adulthood reported in the medical literature. Our patient underwent Roux-en-Y duodenojejunostomy and had symptomatic relief following the successful surgery.

IntroductionIntestinal malrotation is defined as intestinal nonrotation or incomplete rotation around superior mesenteric artery (SMA), involving anomalies of intestinal fixation as well. The patients may be recognized incidentally during other surgical procedures or at autopsy. Here in, we present a case of midgut malrotation which was diagnosed incidentally during hepaticojejunostomy procedure for benign biliary stricture.Presentation of caseA 46 years old male patient was referred to our clinic with failed surgery for biliary stricture due to extensive adhesions. Prior to our surgery, intestinal malrotation was not reported and noticed by the diagnostic tools. When the patient underwent relaparotomy, midgut malrotation was observed.DiscussionDistruption in the normal embryological development of bowel is the cause of intestinal malrotation. Various anatomic configurations and anomalies resulting from rotation anomalies of midgut. Adult patients are usually asymptomatic and the anomaly is discovered only at autopsy or incidentally at surgery. The role of additional surgery especially in patients with asymptomatic disease related to malrotation is debated.ConclusionPerforming loop hepaticojejunostomy with Braun enteroenterostomy is feasible and acceptable option rather than Roux-N-Y hepaticojejunostomy in case of intestinal malrotation.

Up to half of all internal hernias are caused by paraduodenal hernia, a rare congenital midgut malrotation that accounts for less than 1% of all intestinal obstructions. The diagnosis may arise from an incidental finding on abdominal imaging or the patient may present with abdominal pain, vomiting, and obstipation. Early recognition and management of this disease entity are keys because serious complications such as bowel ischemia and infarction may result from a delay in diagnosis. We present a case involving a 14-year-old boy with gangrenous small bowel secondary to right paraduodenal hernia.

In patients presenting with abdominal pain, appendicitis is the most common surgical disorder. Appendicitis causing pain in the left lower quadrant is extremely rare and can occur with congenital abnormalities that include true left-sided appendix or as an atypical presentation of right-sided long appendix, which projects into the left lower quadrant. We report a case of a 69-year-old man showing midgut malrotation with acute appendicitis presenting as left lower quadrant abdominal pain.

The ability to provide cross-sectional imaging, combined with a lack of ionizing radiation has made magnetic resonance imaging (MRI) of abdomen popular. We report four interesting cases: Midgut malrotation with volvulus, sigmoid volvulus, biliary rupture of hydatid cyst, and small bowel lipomatosis, where fast imaging employing steady-state acquisition [FIESTA]/constructive interference into steady state [CISS] sequence helped in clinching the diagnosis.

Unexpected midgut malrotation (MM) was encountered during laparoscopic Roux-en-Y gastric bypass for obesity. This procedure, being performed for the first time within our trust, was completed nonetheless without any postoperative complications. MM is a rare condition in adults, with a comprehensive literature review finding a paucity of reports of MM during bariatric procedures.

Intestinal malrotation in adults is usually an incidental finding on computed tomography (CT). We present the CT findings of 18 adult patients with malrotation and discuss the clinical implications.Abdominal scans of 18 patients (12 women, six men; age range = 15-79 years) with intestinal malrotation were reviewed. Special attention was directed to the location of the superior mesenteric vessels, the location of the small and large bowels, the size of the uncinate process, the situs definition, and additional anomalies.The malrotation was an incidental finding in all but one patient. The malrotation was type Ia in 17 patients and IIc in the one symptomatic patient. The superior mesenteric vessels were vertically oriented in 10, inverted in two, normally positioned in four, and mirror imaged in two cases with situs ambiguus. All patients had aplasia of the pancreatic uncinate process, five had a short pancreas, and two had a preduodenal portal vein. Fourteen patients had a normal situs and four had heterotaxia. Seven patients had polysplenia, six of which with associated inferior vena cava anomalies.Intestinal malrotation can be diagnosed on CT by the anatomic location of a right-sided small bowel, left-sided colon, an abnormal relationship of the superior mesenteric vessels, and aplasia of the uncinate process. Awareness of these abnormalities is necessary to diagnose this anomaly. It should be sought in patients with a situs problem, inferior vena cava anomalies, polysplenia, or preduodenal portal vein. Although usually an incidental finding, it is important to diagnose such a malrotation because it may cause abdominal symptoms. Also, knowledge of associated vascular anomalies is important when abdominal surgery is planned.

Midgut malrotation and volvulus, found mostly in children, are rare and difficult to diagnose preoperatively in adults. We report 2 cases in which a 68-year-old man and a 75-year-old woman presented with intermittent cramping abdominal pain, abdominal distention, and vomiting. Abdominal sonography demonstrated wrapping of the superior mesenteric vein and bowel loops around the superior mesenteric artery (the “whirlpool sign”) in both patients. Abdominal CT revealed similar findings. The diagnoses of midgut volvulus and mesenteric malrotation were made, and the patients underwent laparotomy. The man was confirmed to have duodenojejunal malrotation and volvulus, and the woman had cecal volvulus. The whirlpool sign is valuable for the preoperative diagnosis of mesenteric vessel malrotation and midgut volvulus. © 1999 John Wiley & Sons, Inc. J Clin Ultrasound 27:279–283, 1999.