This document presents a case report of a 20-year-old male who presented with abdominal pain and vomiting due to midgut volvulus and malrotation, an unusual cause of intestinal obstruction in adults. Imaging including abdominal radiographs and CT showed dilated bowel loops and abnormal vascular relationships indicative of malrotation. The patient underwent surgery which confirmed malrotation of the bowel with Ladd's bands causing midgut volvulus. Malrotation results from abnormal rotation of the bowel during fetal development and typically presents in infants, but can occasionally cause obstruction in adults.

1. MIDGUT VOLVULUS AND MALROTATION : AN UNUSUAL CAUSE OF
INTESTINAL OBSTRUCTION IN ADULTS
Dr Nafeesa Jameel*, Dr Rekha Gupta# , Dr Shreya Gupta *
*Junior Resident , Department of Radio-diagnosis , Govt. Medical college
and hospital , Chandigarh
#Assistant Professor , Department of Radio-diagnosis , Govt. Medical
college and hospital , Chandigarh

2. Case Presentation
A 20-year-old male patient presented to the surgery emergency with a two-
day history of pain abdomen, vomiting and abdominal distention.
Previous History : intermittent episodes of diffuse pain abdomen for past 8
months.
No significant past medical , family or surgical history was found.
On physical examination the patient was afebrile and haemodynamically
stable . There was generalised abdominal tenderness with voluntary
guarding, however, no signs of peritonitis were noted.
Underwent abdominal radiographs and contrast-enhanced computed
tomography (CECT) abdomen in our department.

3. Abdominal radiograph and Contrast enhanced
computed tomography(CECT) images of whole
abdomen : a.) Frontal erect abdominal radiograph
showing dilated large bowel loops with multiple air
fluid levels. b.) Ileocecal junction (red arrow) is
seen in the midline in the coronal reconstruction of
CECT images.
Axial view through the lower abdomen showing c.) abrupt narrowing and beaking
of the mid ileal loop (red arrow), d.) partial clockwise rotation of the mesentry
(blue arrow) , e.) dilated small bowel loops (yellow arrow) with reversed SMA-
SMV relationship with SMV seen lying to the left of the SMA(green arrow) f.)
small bowel loops seen occupying the right side of the abdominal cavity and the
large bowel loops on the left side of the abdominal cavity (pink arrow).

4. Figure 3 : Intra-operative images a.) dilated small bowel
loops b.)presence of Meckel’s diverticulum (white arrow)
The patient underwent a timely Ladd’s
procedure with caecopexy and diverticulectomy.
Intraoperative findings confirmed the dilated
small bowel loops with non-rotated bowel
configuration and midgut volvulus with Ladd’s
bands.
Imaging findings were suggestive of
o Dilated small bowel loops
o Reversed SMA-SMV relationship
o Small bowel loops seen occupying the
right side of the abdominal cavity and
the large bowel loops on the left side of
the abdominal cavity

5. Schematic representation of normal embryological development of bowel loops : a.)Physiological midgut herniation at 5th week of fetal
development b.)90 0 counter-clockwise rotation around the superior mesenteric artery axis (SMA axis) c.) 270 0 counter-clockwise rotation after
10 week of gestation during the process of reduction into the abdominal cavity d.) descent of the caecum and fixation of the mesentery
• Malrotation : developmental abnormality
characterised by abnormal rotation & fixation of
small bowel mesentery.
• Occurs due to deviation from the normal 270 0
counter-clockwise rotation of the gut around the
SMA axis during embryonic development from 10th
to 11th week.
• A number of variations of malrotation : based on the
degree of midgut rotation in the umbilical cord ,
during and after reduction into the abdominal cavity-
 Nonrotation - Cessation of midgut rotation at
90o counter-clockwise rotation within the
umbilical cord .
 Malrotation : Failure of midgut to complete
180 0 counter clockwise rotation after the initial
90 0 rotation within the umbilical cord. (2)
 Reverse rotation
 Hyper-rotation

6. Discussion
• Malrotation is a common cause of intestinal obstruction in neonates , only 0.2-0.5% of cases present in adulthood, of
which only 15% have midgut volvulus. (1)
• Malrotation of the gut and malposition of the caecum produces a narrow mesenteric fixation which is more prone to midgut
volvulus and obstruction. Abnormal peritoneal fibrous bands (Ladd’s bands) may persist from malpositioned caecum to
right lateral abdominal wall and liver and predispose to intestinal obstruction.(3)
• Meckel’s diverticulum is one of the commonest abnormalities of omphalomesenteric duct involution which occurs at the
same time during embryogenesis as gut rotation. Only a few cases of concurrent Meckel’s diverticulum and malrotation
have been reported to date.(4)
• Clinical Presentation: In adults is usually asymptomatic or may present with non-specific gastrointestinal symptoms like
abdominal pain, indigestion or rarely as acute abdomen secondary to midgut volvulus. (5)
• Diagnostic modalities :
 Frontal plain radiography may show right-sided jejunal markings with the absence of a stool-filled colon in the right
lower quadrant.
 Abdominal colour doppler ultrasound , malposition of the SMA can be seen.(5,6)
 Secondary signs of midgut volvulus including duodenal dilatation with beak like tapering and whirlpool sign of
mesenteric twisting around the SMA axis.(7)
 Upper Gastrointestinal (UGI) contrast study : abnormally located duodenojejunal flexure which fails to cross the left
pedicle of corresponding upper lumbar vertebra and may be positioned caudal to the level of the duodenal bulb.
Corkscrew appearance of the proximal small bowel is indicative of midgut volvulus.(5,6)
 CECT and MRI scans are highly sensitive to demonstrate these findings with benefit of spatial resolution and
multiplanar imaging. However, abnormal orientation of the SMA-SMV relationship is not specific for malrotation as
both false positives and negatives have been reported.(5)
• Associations - hypoplastic or absent uncinate process of the pancreas, possibly due to incomplete rotation of pancreatic
ventral bud along. It has been shown to be associated with mesenteric vascular inversion.(5,8)

7. References
1. Torres AM, Ziegler MM: Malrotation of the intestine. World J Surg 1993, 17:326-331.
2. Strouse P. Disorders of intestinal rotation and fixation (?malrotation?). Pediatric Radiology.
2004;34(11):837-851.
3. Fu T, Tong WD, He YJ, Wen YY, Luo DL, Liu BH: Surgical management of intestinal
malrotation in adults. World Journal of Surgery 2007, 31:1797-1803.
4. Taylor H, Venza M, Badvie S. Concurrent perforated Meckel's diverticulum and intestinal
malrotation in an 8-year-old boy: Figure 1. BMJ Case Reports. 2015;:bcr2015212377.
5. Pickhardt PJ, Bhalla S: Intestinal malrotation in adolescents and adults: spectrum of clinical
and imaging features. American Journal of Radiology 2002, 179:1429-1435.
6. Kapfer SA, Rappold JF: Intestinal malrotation - not just the paediatric surgeon’s problem. J
Am Coll Surg 2004, 199:628-635.
7. Pacros JP, Sann L, Genin G, Tran-Minh VA, Morin de Finfe CH, Foray P, Louis D:
Ultrasound diagnosis of midgut volvulus: the ‘whirlpool’ sign. Paediatr Radiology 1992,
22:18-20.
8. Inoue Y, Nakamura H. Aplasia or hypoplasia of the pancreatic uncinate process: comparison
in patients with and patients without intestinal nonrotation. Radiology. 1997;205(2):531-533.