RECURRENT SUB -ACUTE INTESTINAL OBSTRUCTION PRESENTED AS MIDGUT MALROTATION WITH VOLVULUS MANAGED BY LAAD'S PROCEDURE AND SURGERY IN AN ADULT PATIENT: A CASE REPORT AND LITERATURE REVIEW

Abstract

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.