{"paper_id":"36b6cc6a-a45f-4d9b-abf5-5b8cd85313f4","body_text":"Midgut Volvulus Secondary to Intestinal Malrotation and Meckel’s Diverticulitis: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Midgut Volvulus Secondary to Intestinal Malrotation and Meckel’s Diverticulitis: A Case Report Bhawesh Bhattarai, Prajjwol Luitel, Sujan Poudel, Suraj Pariyar, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5164274/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Volvulus, a condition where the intestines twist upon themselves, is a serious surgical emergency that commonly affects children. Midgut volvulus is frequently caused by congenital malrotation, a developmental anomaly where the intestines fail to rotate and fixate properly during fetal development. Although Meckel's diverticulum, the most prevalent gastrointestinal congenital anomaly, occurs in approximately 2% of the population, its coexistence with intestinal malrotation is rare. Case Presentation: A 7-year-old boy presented with recurrent abdominal pain and bilious vomiting over the past month, worsening in recent weeks. Physical examination revealed mild abdominal distension and tenderness, with stable vitals. Laboratory findings indicated mild leukocytosis and elevated C-reactive protein, suggesting inflammation. Imaging studies, including X-ray, ultrasound, and contrast-enhanced CT, revealed features of small bowel obstruction, midgut volvulus, and intestinal malrotation. An emergency exploratory laparotomy confirmed a volvulus caused by a fibrous band of the vitelline duct, with Meckel's diverticulum and an inflamed appendix. The patient underwent wedge excision of the Meckel’s diverticulum and appendectomy, with an uneventful recovery. He was discharged on postoperative day 4 and remained symptom-free at a 6-month follow-up. Discussion and Conclusion: Midgut volvulus, primarily caused by intestinal malrotation, is a life-threatening condition in children that can lead to bowel obstruction and ischemia. While malrotation accounts for 70-80% of volvulus cases, rarer causes, such as Meckel's diverticulum, contribute to fewer than 5%. In this case, the volvulus was further complicated by a fibrous band associated with Meckel’s diverticulitis and concurrent appendicitis. Surgical intervention, including Ladd’s procedure, wedge excision of the Meckel’s diverticulum, and appendectomy, was crucial in preventing further complications. Early diagnosis and prompt surgical correction are essential to avoid volvulus-related morbidity. This case highlights the importance of recognizing coexisting conditions like Meckel’s diverticulitis and appendicitis, which can exacerbate volvulus. The patient recovered uneventfully and remained symptom-free at follow-up, emphasizing the necessity of timely surgical intervention for successful outcomes. Midgut Volvulus Intestinal Malrotation Meckel’s Diverticulitis Figures Figure 1 Figure 2 Background Volvulus, a condition where the intestines twist upon themselves, can occur at any age but is more common in children and infants [ 1 ]. Congenital malrotation is the leading cause of midgut volvulus in children, accounting for 70–80% of cases, followed by intestinal adhesions (10–15%), anatomical variations (5–10%), and less commonly, conditions like meconium ileus or other congenital anomalies (under 5%) [ 2 – 4 ]. Intestinal malrotation is a developmental anomaly of the midgut in which the normal foetal rotation of intestines around the superior mesenteric artery and their fixation in the peritoneal cavity fail [ 5 ]. This malrotation and mal-fixation result in narrow mesenteric base leading to a midgut volvulus and the formation of Ladd's bands in neonates and young children [ 6 ]. In older children and adults, abdominal pain is the most common symptom which may present with abrupt onset over hours or days or as chronic intermittent pain over weeks, months followed by Intermittent vomiting, chronic diarrhoea, malabsorption, or failure to thrive comprise other potential presenting symptoms [ 3 , 7 ]. Meckel's diverticulum is the most common gastrointestinal congenital anomaly occurring in approximately 2% of the population resulting from incomplete atrophy of the vitelline duct [ 8 , 9 ]. While both Meckel's diverticulum and intestinal malrotation are significant congenital anomalies, their simultaneous occurrence is infrequent and documented primarily through isolated case reports rather than large-scale studies [ 10 ]. This report adhering to the CARE guidelines discusses a rare case of concomitant occurrence of Meckel's diverticulum and intestinal malrotation as a cause of volvulus in a 7-years-old boy [ 11 ]. Case Presentation A 7-years-old male presented with recurrent episodes of abdominal pain and multiple episodes of bilious vomiting over the past month. He had no associated symptoms such as anorexia, significant weight loss or changes in bowel and bladder habits. The symptoms had worsened over the past few weeks, prompting medical consultation. There was no significant past medical history. No history constipation, blood in stool. On physical examination, vitals were stable with mild abdominal distension and tenderness but no palpable masses. Bowel sounds were slightly exaggerated, and no signs of peritoneal irritation were present. Laboratory investigations revealed mild leucocytosis with a white blood cell count of 12,500/µL, haemoglobin levels of 12.1 g/dL, and C-reactive protein levels slightly elevated at 8 mg/L, suggestive of an inflammatory process. Electrolytes and liver function tests were within normal limits. An abdominal X-ray revealed findings suggestive of small bowel obstruction, including dilated bowel loops and air-fluid levels. Ultrasound suggested volvulus with the key findings including the “clockwise whirlpool sign”, an inverted SMA/SMV relationship and abnormal or dilated bowel. The Contrast Enhanced Computed Tomography (CECT) scan showed mild dilatation of the bowel loops, with the small bowel located abnormally in the right upper quadrant. The superior mesenteric vein (SMV) was observed to be left-sided relative to the superior mesenteric artery (SMA). In addition, \"whirlpool appearance\" was seen as suggestive of midgut volvulus with intestinal malrotation. ( Fig. 1 ). Patient was kept nil per Os, started on intravenous fluids, analgesics. Due to the progressive nature of the symptoms, an emergency exploratory laparotomy was performed. Intraoperative findings showed a volvulus caused by a fibrous band of the vitelline duct along with the presence of Meckel’s diverticulum (Fig. 3). A segment of small bowel was twisted around the fibrous band, leading to the obstruction. In addition, the appendix was inflamed. Figure: (2a) inflamed Meckel's diverticulum, (2b) inflamed appendix present in subhepatic region suggestive of intestinal malrotation (2c) following splaying of mesentery and lysis of Ladd's band: Intraoperative findings showing a volvulus caused by a fibrous band of the vitelline duct along with the presence of Meckel’s diverticulum. Wedge excision of the inflamed MD and appendectomy was performed. The patient's postoperative recovery was uneventful, with oral intake resumed by postoperative day 3, and he was discharged on postoperative day 4 in stable condition. At follow-up after 6 months, he remained symptom-free with no abdominal complaints. Discussion and Conclusion Midgut volvulus is a serious condition resulting from the twisting of the intestines around the superior mesenteric artery, which can lead to bowel obstruction and ischemia [ 3 ]. Presentation is usually with abdominal pain, proximal small bowel obstruction and bilious vomiting. The primary cause of midgut volvulus in children is congenital intestinal malrotation, a condition where the intestines fail to rotate properly during foetal development [ 2 , 3 ]. This condition accounts for approximately 70–80% of volvulus cases in children. Other causes include intestinal adhesions (10–15%) and anatomical variations (5–10%), while rarer causes, such as congenital anomalies like Meckel's diverticulum, account for fewer than 5% of cases​ [ 4 , 12 , 13 ]. Intestinal malrotation predisposes the intestines to twist around the superior mesenteric artery leading to volvulus. The majority of intestinal malrotation cases are diagnosed in infants within the first year, but in older children, the mean age of diagnosis is around 4.3 years, often delayed due to atypical symptoms, increasing the risk of complications like volvulus or obstruction [ 14 , 15 ]. Meckel’s diverticulum, a remnant of the omphalomesenteric duct, is usually asymptomatic but can lead to complications in 4–40% of cases, including haemorrhage, obstruction, intussusception, and diverticulitis [ 9 ]. Meckel’s diverticulitis can result in the formation of fibrous \"vitelline bands\" that tether parts of the intestines, creating adhesion points that increase the risk of volvulus and obstruction​. In this case, the fibrous bands associated with the inflamed Meckel’s diverticulum likely exacerbated the twisting of the intestines, worsening the obstruction. Furthermore, our patient also presented with appendicitis, adding to complexity. Appendicitis can cause localized inflammation and increase intra-abdominal pressure, potentially exacerbating the obstruction caused by the volvulus. The combination of intestinal malrotation, Meckel’s diverticulitis, and appendicitis contributed to the onset of volvulus and the subsequent bowel obstruction​. It is mandatory to correct the malrotation, whenever the diagnosis is made, due to known devastating consequences of volvulus [ 7 ]. Surgical intervention is crucial in cases like this, where multiple factors contribute to the development of midgut volvulus. Ladd's procedure is performed with open technique to treat the intestinal malrotation, and has been the gold standard and involves the division of Ladd's bands, de-rotation of volvulus, straightening of duodenum, widening of mesentery and appendectomy [ 7 ]. The combination of Meckel’s diverticulitis and intestinal malrotation, as observed in our patient, is exceedingly rare, but both conditions individually warrant surgical intervention when symptomatic. In our case, an emergency laparotomy was performed due to the progressive symptoms and imaging findings consistent with midgut volvulus. The procedure involved a segmental small-bowel resection with primary anastomosis, along with the wedge excision of Meckel’s diverticulum and the associated fibrous band. The malrotation was corrected and the inflamed appendicitis was also removed. This timely intervention likely prevented further complications, and the patient made a good recovery with no recurrence of symptoms​. In conclusion, midgut volvulus secondary to intestinal malrotation, complicated by Meckel’s diverticulitis, represents a rare but serious surgical emergency in children. Prompt diagnosis and intervention are critical to prevent bowel ischemia and other life-threatening complications. This case highlights the importance of recognizing the potential for multiple coexisting conditions, such as Meckel’s diverticulitis and appendicitis, that can exacerbate volvulus. Surgical correction through Ladd's procedure, alongside resection of the Meckel’s diverticulum and appendectomy, ensured a successful outcome with no recurrence, emphasizing the efficacy of timely surgical management. Abbreviations MD Meckel’s Diverticulum CECT Contrast Enhanced Computed Tomography SMV Superior Mesenteric Vein SMA Superior Mesenteric Artery Declarations Ethics Approval and Consent to Participate: Not applicable. Consent for Publication: Written informed consent was obtained from the patient’s parents for publication of this case report and accompanying images. Competing Interests: The authors declare that they have no competing interests. Funding: No funding was received for this case report. Author Contribution B.B. and D.K. conceptualized of the case. Patient management was carried out by B.B. and D.K. The original draft of the manuscript was written by B.B., P.L., S.P., S.P., A.D., and D.K., with all authors contributing to the review and editing process. Visualization and supervision of the project were provided by D.K. Availability of Data and Materials: Not applicable. References Millar AJW, Rode H, Cywes S. Malrotation and volvulus in infancy and childhood. Semin Pediatr Surg. 2003;12:229–36. https://doi.org/10.1053/j.sempedsurg.2003.08.003 . Baba Y, Gaillard F. Midgut volvulus. Radiopaedia.org, Radiopaedia.org; 2008. https://doi.org/10.53347/rID-1675 Coste AH, Anand S, Nada H, Ahmad H. Midgut Volvulus. Treasure Island (FL): StatPearls Publishing;: StatPearls; 2024. Ramirez-Merced EJ, Arizmendi-Velez GE, Sharma R, Guarecuco Castillo JE, El-Tawil R, Masri MM. Midgut Volvulus on an Octogenarian Male: A Case Report. Cureus 2023. https://doi.org/10.7759/cureus.41667 Devkota S, Luitel P, Paudel S, Neupane N, Dev S, Kansakar PBS. Incidentally discovered intestinal malrotation during evaluation for blunt abdominal trauma: A case report. Int J Surg Case Rep. 2024;116:109430. https://doi.org/10.1016/j.ijscr.2024.109430 . Andrassy CRJ. Malrotation of the Midgut in Infants and Children: A 25-Year Review. Arch Surg. 1981;116:158. https://doi.org/10.1001/archsurg.1981.01380140020004 . Agrawal V, Tiwari A, Acharya H, Mishra R, Sharma D. Laparoscopic steering wheel derotation technique for midgut volvulus in children with intestinal malrotation. J Minimal Access Surg. 2019;15:219. https://doi.org/10.4103/jmas.JMAS_24_18 . Dev S, Luitel P, Paudel S, Karki B, Dev B, Dahal GR. Coexistence of cecal duplication cyst and Meckel’s diverticulum presenting as intestinal obstruction: A case report. Int J Surg Case Rep. 2024;121:109943. https://doi.org/10.1016/j.ijscr.2024.109943 . Choi S, Hong SS, Park HJ, Lee HK, Shin HC, Choi GC. The many faces of Meckel’s diverticulum and its complications. J Med Imaging Radiat Oncol. 2017;61:225–31. https://doi.org/10.1111/1754-9485.12505 . Taylor H, Venza M, Badvie S. Concurrent perforated Meckel’s diverticulum and intestinal malrotation in an 8-year-old boy. BMJ Case Rep. 2015;bcr2015212377. https://doi.org/10.1136/bcr-2015-212377 . Riley DS, Barber MS, Kienle GS, Aronson JK, von Schoen-Angerer T, Tugwell P, et al. CARE guidelines for case reports: explanation and elaboration document. J Clin Epidemiol. 2017;89:218–35. https://doi.org/10.1016/j.jclinepi.2017.04.026 . Ahmadi Amoli H, Rahimpour E, Firoozeh N, Abbaszadeh-Kasbi A, Jazaeri SA. Midgut volvulus is a rare cause of intestinal obstruction in adults: A case report. Int J Surg Case Rep. 2019;58:41–4. https://doi.org/10.1016/j.ijscr.2019.03.029 . Chong E, Liu DS, Strugnell N, Rajagopal V, Mori KK. Midgut Volvulus: A Rare but Fatal Cause of Abdominal Pain in Pregnancy—How Can We Diagnose and Prevent Mortality? Obstet Gynecol Int. 2020;2020:1–5. https://doi.org/10.1155/2020/2185290 . Spigland N, Brandt ML, Yazbeck S. Malrotation presenting beyond the neonatal period. J Pediatr Surg. 1990;25:1139–42. https://doi.org/10.1016/0022-3468(90)90749-Y . Durkin ET, Lund DP, Shaaban AF, Schurr MJ, Weber SM. Age-Related Differences in Diagnosis and Morbidity of Intestinal Malrotation. J Am Coll Surg. 2008;206:658–63. https://doi.org/10.1016/j.jamcollsurg.2007.11.020 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-5164274\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":true,\"archivedVersions\":[],\"articleType\":\"Case Report\",\"associatedPublications\":[],\"authors\":[{\"id\":361844782,\"identity\":\"b51a0f3d-77dc-4096-8aa0-d0152142c319\",\"order_by\":0,\"name\":\"Bhawesh Bhattarai\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Tribhuvan University Teaching Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Bhawesh\",\"middleName\":\"\",\"lastName\":\"Bhattarai\",\"suffix\":\"\"},{\"id\":361844783,\"identity\":\"b4fbe970-e527-40b1-a3a2-3acb77e26783\",\"order_by\":1,\"name\":\"Prajjwol 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1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":13684,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eCECT showing \\\"whirlpool appearance”\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Picture1.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5164274/v1/149e9285ccc13427bcdeaf91.jpg\"},{\"id\":68716330,\"identity\":\"bb48bc41-3d3a-421b-98cd-222d2913387c\",\"added_by\":\"auto\",\"created_at\":\"2024-11-11 09:57:31\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":447866,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e(2a) inflamed Meckel's diverticulum, (2b) inflamed appendix present in subhepatic region suggestive of intestinal malrotation (2c) following splaying of mesentery and lysis of Ladd's band: Intraoperative findings showing a volvulus caused by a fibrous band of the vitelline duct along with the presence of Meckel’s diverticulum.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Picture2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5164274/v1/5aaf4d4997128b7b40518109.png\"},{\"id\":69885382,\"identity\":\"c40fd0fc-bf39-4fdd-a56c-a2e959609d7e\",\"added_by\":\"auto\",\"created_at\":\"2024-11-26 09:39:07\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":681921,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5164274/v1/f7741faa-bbcf-4f78-a189-4bf399a4ea53.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"\\u003cp\\u003eMidgut Volvulus Secondary to Intestinal Malrotation and Meckel’s Diverticulitis: A Case Report\\u003c/p\\u003e\",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003cp\\u003eVolvulus, a condition where the intestines twist upon themselves, can occur at any age but is more common in children and infants [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e]. Congenital malrotation is the leading cause of midgut volvulus in children, accounting for 70\\u0026ndash;80% of cases, followed by intestinal adhesions (10\\u0026ndash;15%), anatomical variations (5\\u0026ndash;10%), and less commonly, conditions like meconium ileus or other congenital anomalies (under 5%) [\\u003cspan additionalcitationids=\\\"CR3\\\" citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eIntestinal malrotation is a developmental anomaly of the midgut in which the normal foetal rotation of intestines around the superior mesenteric artery and their fixation in the peritoneal cavity fail [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eThis malrotation and mal-fixation result in narrow mesenteric base leading to a midgut volvulus and the formation of Ladd's bands in neonates and young children [\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e]. In older children and adults, abdominal pain is the most common symptom which may present with abrupt onset over hours or days or as chronic intermittent pain over weeks, months followed by Intermittent vomiting, chronic diarrhoea, malabsorption, or failure to thrive comprise other potential presenting symptoms [\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eMeckel's diverticulum is the most common gastrointestinal congenital anomaly occurring in approximately 2% of the population resulting from incomplete atrophy of the vitelline duct [\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eWhile both Meckel's diverticulum and intestinal malrotation are significant congenital anomalies, their simultaneous occurrence is infrequent and documented primarily through isolated case reports rather than large-scale studies [\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eThis report adhering to the CARE guidelines discusses a rare case of concomitant occurrence of Meckel's diverticulum and intestinal malrotation as a cause of volvulus in a 7-years-old boy [\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e].\\u003c/p\\u003e\"},{\"header\":\"Case Presentation\",\"content\":\"\\u003cp\\u003eA 7-years-old male presented with recurrent episodes of abdominal pain and multiple episodes of bilious vomiting over the past month. He had no associated symptoms such as anorexia, significant weight loss or changes in bowel and bladder habits. The symptoms had worsened over the past few weeks, prompting medical consultation. There was no significant past medical history. No history constipation, blood in stool.\\u003c/p\\u003e \\u003cp\\u003eOn physical examination, vitals were stable with mild abdominal distension and tenderness but no palpable masses. Bowel sounds were slightly exaggerated, and no signs of peritoneal irritation were present.\\u003c/p\\u003e \\u003cp\\u003eLaboratory investigations revealed mild leucocytosis with a white blood cell count of 12,500/\\u0026micro;L, haemoglobin levels of 12.1 g/dL, and C-reactive protein levels slightly elevated at 8 mg/L, suggestive of an inflammatory process. Electrolytes and liver function tests were within normal limits.\\u003c/p\\u003e \\u003cp\\u003eAn abdominal X-ray revealed findings suggestive of small bowel obstruction, including dilated bowel loops and air-fluid levels. Ultrasound suggested volvulus with the key findings including the \\u0026ldquo;clockwise whirlpool sign\\u0026rdquo;, an inverted SMA/SMV relationship and abnormal or dilated bowel. The Contrast Enhanced Computed Tomography (CECT) scan showed mild dilatation of the bowel loops, with the small bowel located abnormally in the right upper quadrant. The superior mesenteric vein (SMV) was observed to be left-sided relative to the superior mesenteric artery (SMA). In addition, \\\"whirlpool appearance\\\" was seen as suggestive of midgut volvulus with intestinal malrotation. \\u003cb\\u003e(\\u003c/b\\u003eFig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e\\u003cb\\u003e).\\u003c/b\\u003e\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003ePatient was kept nil per Os, started on intravenous fluids, analgesics. Due to the progressive nature of the symptoms, an emergency exploratory laparotomy was performed.\\u003c/p\\u003e \\u003cp\\u003eIntraoperative findings showed a volvulus caused by a fibrous band of the vitelline duct along with the presence of Meckel\\u0026rsquo;s diverticulum (Fig.\\u0026nbsp;3). A segment of small bowel was twisted around the fibrous band, leading to the obstruction. In addition, the appendix was inflamed.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003eFigure: (2a) inflamed Meckel's diverticulum, (2b) inflamed appendix present in subhepatic region suggestive of intestinal malrotation (2c) following splaying of mesentery and lysis of Ladd's band: Intraoperative findings showing a volvulus caused by a fibrous band of the vitelline duct along with the presence of Meckel\\u0026rsquo;s diverticulum.\\u003c/p\\u003e \\u003cp\\u003eWedge excision of the inflamed MD and appendectomy was performed. The patient's postoperative recovery was uneventful, with oral intake resumed by postoperative day 3, and he was discharged on postoperative day 4 in stable condition.\\u003c/p\\u003e \\u003cp\\u003eAt follow-up after 6 months, he remained symptom-free with no abdominal complaints.\\u003c/p\\u003e \"},{\"header\":\"Discussion and Conclusion\",\"content\":\"\\u003cp\\u003eMidgut volvulus is a serious condition resulting from the twisting of the intestines around the superior mesenteric artery, which can lead to bowel obstruction and ischemia [\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e]. Presentation is usually with abdominal pain, proximal small bowel obstruction and bilious vomiting. The primary cause of midgut volvulus in children is congenital intestinal malrotation, a condition where the intestines fail to rotate properly during foetal development [\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e]. This condition accounts for approximately 70\\u0026ndash;80% of volvulus cases in children. Other causes include intestinal adhesions (10\\u0026ndash;15%) and anatomical variations (5\\u0026ndash;10%), while rarer causes, such as congenital anomalies like Meckel's diverticulum, account for fewer than 5% of cases​ [\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eIntestinal malrotation predisposes the intestines to twist around the superior mesenteric artery leading to volvulus. The majority of intestinal malrotation cases are diagnosed in infants within the first year, but in older children, the mean age of diagnosis is around 4.3 years, often delayed due to atypical symptoms, increasing the risk of complications like volvulus or obstruction [\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eMeckel\\u0026rsquo;s diverticulum, a remnant of the omphalomesenteric duct, is usually asymptomatic but can lead to complications in 4\\u0026ndash;40% of cases, including haemorrhage, obstruction, intussusception, and diverticulitis [\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eMeckel\\u0026rsquo;s diverticulitis can result in the formation of fibrous \\\"vitelline bands\\\" that tether parts of the intestines, creating adhesion points that increase the risk of volvulus and obstruction​. In this case, the fibrous bands associated with the inflamed Meckel\\u0026rsquo;s diverticulum likely exacerbated the twisting of the intestines, worsening the obstruction.\\u003c/p\\u003e \\u003cp\\u003eFurthermore, our patient also presented with appendicitis, adding to complexity. Appendicitis can cause localized inflammation and increase intra-abdominal pressure, potentially exacerbating the obstruction caused by the volvulus. The combination of intestinal malrotation, Meckel\\u0026rsquo;s diverticulitis, and appendicitis contributed to the onset of volvulus and the subsequent bowel obstruction​.\\u003c/p\\u003e \\u003cp\\u003eIt is mandatory to correct the malrotation, whenever the diagnosis is made, due to known devastating consequences of volvulus [\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eSurgical intervention is crucial in cases like this, where multiple factors contribute to the development of midgut volvulus.\\u003c/p\\u003e \\u003cp\\u003eLadd's procedure is performed with open technique to treat the intestinal malrotation, and has been the gold standard and involves the division of Ladd's bands, de-rotation of volvulus, straightening of duodenum, widening of mesentery and appendectomy [\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eThe combination of Meckel\\u0026rsquo;s diverticulitis and intestinal malrotation, as observed in our patient, is exceedingly rare, but both conditions individually warrant surgical intervention when symptomatic.\\u003c/p\\u003e \\u003cp\\u003eIn our case, an emergency laparotomy was performed due to the progressive symptoms and imaging findings consistent with midgut volvulus. The procedure involved a segmental small-bowel resection with primary anastomosis, along with the wedge excision of Meckel\\u0026rsquo;s diverticulum and the associated fibrous band. The malrotation was corrected and the inflamed appendicitis was also removed. This timely intervention likely prevented further complications, and the patient made a good recovery with no recurrence of symptoms​.\\u003c/p\\u003e \\u003cp\\u003eIn conclusion, midgut volvulus secondary to intestinal malrotation, complicated by Meckel\\u0026rsquo;s diverticulitis, represents a rare but serious surgical emergency in children. Prompt diagnosis and intervention are critical to prevent bowel ischemia and other life-threatening complications. This case highlights the importance of recognizing the potential for multiple coexisting conditions, such as Meckel\\u0026rsquo;s diverticulitis and appendicitis, that can exacerbate volvulus. Surgical correction through Ladd's procedure, alongside resection of the Meckel\\u0026rsquo;s diverticulum and appendectomy, ensured a successful outcome with no recurrence, emphasizing the efficacy of timely surgical management.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cdiv class=\\\"DefinitionList\\\"\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eMD\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eMeckel\\u0026rsquo;s Diverticulum\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eCECT\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eContrast Enhanced Computed Tomography\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eSMV\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eSuperior Mesenteric Vein\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eSMA\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eSuperior Mesenteric Artery\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003c/div\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e \\u003cstrong\\u003eEthics Approval and Consent to Participate:\\u003c/strong\\u003e \\u003cp\\u003eNot applicable.\\u003c/p\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cstrong\\u003eConsent for Publication:\\u003c/strong\\u003e \\u003cp\\u003eWritten informed consent was obtained from the patient\\u0026rsquo;s parents for publication of this case report and accompanying images.\\u003c/p\\u003e \\u003c/p\\u003e\\u003cp\\u003e \\u003ch2\\u003eCompeting Interests:\\u003c/h2\\u003e \\u003cp\\u003eThe authors declare that they have no competing interests.\\u003c/p\\u003e \\u003c/p\\u003e\\u003ch2\\u003eFunding:\\u003c/h2\\u003e \\u003cp\\u003eNo funding was received for this case report.\\u003c/p\\u003e\\u003ch2\\u003eAuthor Contribution\\u003c/h2\\u003e\\u003cp\\u003eB.B. and D.K. conceptualized of the case. Patient management was carried out by B.B. and D.K. The original draft of the manuscript was written by B.B., P.L., S.P., S.P., A.D., and D.K., with all authors contributing to the review and editing process. Visualization and supervision of the project were provided by D.K.\\u003c/p\\u003e\\u003ch2\\u003eAvailability of Data and Materials:\\u003c/h2\\u003e \\u003cp\\u003eNot applicable.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eMillar AJW, Rode H, Cywes S. Malrotation and volvulus in infancy and childhood. Semin Pediatr Surg. 2003;12:229\\u0026ndash;36. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1053/j.sempedsurg.2003.08.003\\u003c/span\\u003e\\u003cspan address=\\\"10.1053/j.sempedsurg.2003.08.003\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBaba Y, Gaillard F. Midgut volvulus. Radiopaedia.org, Radiopaedia.org; 2008. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.53347/rID-1675\\u003c/span\\u003e\\u003cspan address=\\\"10.53347/rID-1675\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCoste AH, Anand S, Nada H, Ahmad H. Midgut Volvulus. Treasure Island (FL): StatPearls Publishing;: StatPearls; 2024.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eRamirez-Merced EJ, Arizmendi-Velez GE, Sharma R, Guarecuco Castillo JE, El-Tawil R, Masri MM. Midgut Volvulus on an Octogenarian Male: A Case Report. Cureus 2023. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.7759/cureus.41667\\u003c/span\\u003e\\u003cspan address=\\\"10.7759/cureus.41667\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eDevkota S, Luitel P, Paudel S, Neupane N, Dev S, Kansakar PBS. Incidentally discovered intestinal malrotation during evaluation for blunt abdominal trauma: A case report. 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Int J Surg Case Rep. 2024;121:109943. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1016/j.ijscr.2024.109943\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.ijscr.2024.109943\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eChoi S, Hong SS, Park HJ, Lee HK, Shin HC, Choi GC. The many faces of Meckel\\u0026rsquo;s diverticulum and its complications. J Med Imaging Radiat Oncol. 2017;61:225\\u0026ndash;31. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1111/1754-9485.12505\\u003c/span\\u003e\\u003cspan address=\\\"10.1111/1754-9485.12505\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eTaylor H, Venza M, Badvie S. Concurrent perforated Meckel\\u0026rsquo;s diverticulum and intestinal malrotation in an 8-year-old boy. BMJ Case Rep. 2015;bcr2015212377. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1136/bcr-2015-212377\\u003c/span\\u003e\\u003cspan address=\\\"10.1136/bcr-2015-212377\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eRiley DS, Barber MS, Kienle GS, Aronson JK, von Schoen-Angerer T, Tugwell P, et al. CARE guidelines for case reports: explanation and elaboration document. J Clin Epidemiol. 2017;89:218\\u0026ndash;35. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1016/j.jclinepi.2017.04.026\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.jclinepi.2017.04.026\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAhmadi Amoli H, Rahimpour E, Firoozeh N, Abbaszadeh-Kasbi A, Jazaeri SA. Midgut volvulus is a rare cause of intestinal obstruction in adults: A case report. Int J Surg Case Rep. 2019;58:41\\u0026ndash;4. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1016/j.ijscr.2019.03.029\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.ijscr.2019.03.029\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eChong E, Liu DS, Strugnell N, Rajagopal V, Mori KK. Midgut Volvulus: A Rare but Fatal Cause of Abdominal Pain in Pregnancy\\u0026mdash;How Can We Diagnose and Prevent Mortality? Obstet Gynecol Int. 2020;2020:1\\u0026ndash;5. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1155/2020/2185290\\u003c/span\\u003e\\u003cspan address=\\\"10.1155/2020/2185290\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSpigland N, Brandt ML, Yazbeck S. Malrotation presenting beyond the neonatal period. J Pediatr Surg. 1990;25:1139\\u0026ndash;42. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1016/0022-3468(90)90749-Y\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/0022-3468(90)90749-Y\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eDurkin ET, Lund DP, Shaaban AF, Schurr MJ, Weber SM. Age-Related Differences in Diagnosis and Morbidity of Intestinal Malrotation. J Am Coll Surg. 2008;206:658\\u0026ndash;63. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1016/j.jamcollsurg.2007.11.020\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.jamcollsurg.2007.11.020\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Midgut Volvulus, Intestinal Malrotation, Meckel’s Diverticulitis\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-5164274/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-5164274/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003eBackground:\\u003c/p\\u003e\\n\\u003cp\\u003eVolvulus, a condition where the intestines twist upon themselves, is a serious surgical emergency that commonly affects children. Midgut volvulus is frequently caused by congenital malrotation, a developmental anomaly where the intestines fail to rotate and fixate properly during fetal development. Although Meckel's diverticulum, the most prevalent gastrointestinal congenital anomaly, occurs in approximately 2% of the population, its coexistence with intestinal malrotation is rare.\\u003c/p\\u003e\\n\\u003cp\\u003eCase Presentation:\\u003c/p\\u003e\\n\\u003cp\\u003eA 7-year-old boy presented with recurrent abdominal pain and bilious vomiting over the past month, worsening in recent weeks. Physical examination revealed mild abdominal distension and tenderness, with stable vitals. Laboratory findings indicated mild leukocytosis and elevated C-reactive protein, suggesting inflammation. Imaging studies, including X-ray, ultrasound, and contrast-enhanced CT, revealed features of small bowel obstruction, midgut volvulus, and intestinal malrotation. An emergency exploratory laparotomy confirmed a volvulus caused by a fibrous band of the vitelline duct, with Meckel's diverticulum and an inflamed appendix. The patient underwent wedge excision of the Meckel’s diverticulum and appendectomy, with an uneventful recovery. He was discharged on postoperative day 4 and remained symptom-free at a 6-month follow-up.\\u003c/p\\u003e\\n\\u003cp\\u003eDiscussion and Conclusion:\\u003c/p\\u003e\\n\\u003cp\\u003eMidgut volvulus, primarily caused by intestinal malrotation, is a life-threatening condition in children that can lead to bowel obstruction and ischemia. While malrotation accounts for 70-80% of volvulus cases, rarer causes, such as Meckel's diverticulum, contribute to fewer than 5%. In this case, the volvulus was further complicated by a fibrous band associated with Meckel’s diverticulitis and concurrent appendicitis. Surgical intervention, including Ladd’s procedure, wedge excision of the Meckel’s diverticulum, and appendectomy, was crucial in preventing further complications. Early diagnosis and prompt surgical correction are essential to avoid volvulus-related morbidity. This case highlights the importance of recognizing coexisting conditions like Meckel’s diverticulitis and appendicitis, which can exacerbate volvulus. The patient recovered uneventfully and remained symptom-free at follow-up, emphasizing the necessity of timely surgical intervention for successful outcomes.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Midgut Volvulus Secondary to Intestinal Malrotation and Meckel’s Diverticulitis: A Case Report\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2024-11-11 09:57:26\",\"doi\":\"10.21203/rs.3.rs-5164274/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"4d70e911-8ffb-4ed3-ba64-0c2b6bbfbead\",\"owner\":[],\"postedDate\":\"November 11th, 2024\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2024-11-26T09:38:38+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2024-11-11 09:57:26\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-5164274\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-5164274\",\"identity\":\"rs-5164274\",\"version\":[\"v1\"]},\"buildId\":\"qtupq5eGEP_6zYnWcrvyt\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}