Midgut volvulus in an adult without significant intestinal obstruction: A case report.

Informed consent has been obtained to include case details, personal information and images of the patient in publication.

Though mid gut volvulus is a rare entity in adult, its possibility should be excluded in adults presenting with nonspecific abdominal pain or with symptoms of intestinal obstruction.

Midgut volvulus is a rare entity in adult though cases have been reported in literature. There are several predisposing factors. The entity may be primary or may occur secondarily to intestinal malrotation, adhesions, internal hernias, tumors, mesenteric lymph nodes, meckel's diverticulum, lipomas, pregnancy, endometriosis, tuberculosis, aneurysms and hematomas [1] . In our case malrotation was the predisposing factor. Our case report emphasizes on adult presentation of midgut volvulus in post renal transplant patient without features of small bowel obstruction. Intestinal malrotation went undetected in previous imaging done during renal transplant. Intestinal malrotation is a congenital abnormality that arises from disrupting the 270◦ counterclockwise midgut rotation during the embryonic period. Intestinal malrotation exists in multiple forms; the most common are nonrotation, reversed rotation and incomplete rotation. Incomplete rotation is the classical malrotation that is usually described, and is due to rotating 180◦ counterclockwise instead of 270◦, leaving the cecum in the right upper quadrant. Intestinal malrotation can be complicated with volvulus around a narrowed mesentery or bowel obstruction by misplaced peritoneal folds or the SMA [2] . Infants usually present with bilious vomiting. However presentation is non-specific in adults [ 3 ]. Upper Gastrointestinal (GI) series is the preferred diagnostic test for midgut volvulus in neonates with sensitive ranging between 85% and 95% and specificity > 95%. Because the incidence of midgut volvulus in adults is so rare, dedicated fluoroscopy to look for midgut volvulus as an initial diagnostic test would not be practical. CT scan is a useful imaging modality for adult patients with non-specific presentations. Specific findings of midgut volvulus include: whirlpool sign- swirled appearance of the mesentery and superior mesenteric vein (SMV) around the superior mesenteric artery (SMA), malrotated bowel configuration, SMA/SMV transposition, bowel obstruction and pneumoperitoneum [ 4 ]. Ladd's operation is the treatment of choice in both children and adults. Ladd's operation involves counter-clockwise detorsion of the small bowel, surgical division of Ladd's band (fibrous tissue that tethers the intestine) widening of small bowel mesentery, performing appendectomy and replacement of the small bowel to the right and caecum and colon to the left. It can be done via midline incision or laparoscopy [ 5 ].

Small bowel volvulus (SBV) refers to the abnormal twisting of a loop of small bowel around the axis of its own mesentery. Recurrent, intermittent periumbilical or epigastric pain occurring after ingestion of a meal with severity out of proportion to clinical examination is an important clinical finding [1] . Although malrotation is considered a disease of the newborn and pediatric population, cases occurring in adults have occasionally been reported with recent analyses revealing that up to 48% can occur in adulthood [2] . We report you a case of 30 years old male who presented in Emergency department with symptoms of abdominal pain, nausea and vomiting for 3 days. The patient was a renal transplant recipient done 6 years back. Patient was symptomatically managed in emergency with antiemetic, anti-spasmodic and Proton Pump inhibitors (PPI). Routine investigations including Ultrasonography (USG) Abdomen and pelvis along with Doppler of transplanted kidney was done. He had generalized abdominal tenderness, with voluntary guarding but no evidence of peritonism. Further systemic examination was unremarkable. Blood test revealed a white cell count of 12 × 109 L−1, Hb 14.5 gm/dL g, Platelets 3,66,000/cumm. Serum Urea and creatinine were raised to 57 mg/dL and 2.3 mg/dL respectively. Electrolytes and liver function test were within normal range. Plain abdominal and chest films were unremarkable with no free air under the diaphragm or bowel dilatation present. Ultrasonography (USG) Abdomen and pelvis revealed semirotation of small bowel around mesenteric vessels ( Fig. 1 ). However, normal Doppler study of transplanted kidney in right iliac fossa (RIF) was obtained. Fig. 1 USG (Abdomen and Pelvis) showing rotation of bowel loops (block white arrow) around mesenteric vessels (thin white arrow and open white arrow). Fig 1 USG (Abdomen and Pelvis) showing rotation of bowel loops (block white arrow) around mesenteric vessels (thin white arrow and open white arrow). Following this, Contrast Enhanced Computed Tomography (CECT) Abdomen/Pelvis was done. CECT(Abdomen and pelvis) showed location of jejunal loops on right side of colon, inversion of relation of Superior mesenteric vein (SMV) and Superior mesenteric artery (SMA) with SMA being on right of SMV ( Fig. 3 ) and high up position of cecum. Also swirling appearance of superior mesenteric vein was noted around superior mesenteric artery giving rise to classic ‘whirlpool sign’ ( Fig. 2 ). Bilateral native kidneys were atrophic with transplanted kidney located in RIF ( Fig. 4 ). Fig. 2 Arterial and Venous phase CECT axial images showing swirling appearance of SMV (Block white arrow) around SMA (Thin white arrow) giving rise to ‘whirl pool’ sign. Fig 2 Fig. 3 Axial CECT image showing inverted relation of SMV (Block white arrow) and SMA (Thin white arrow). Fig 3 Fig. 4 Coronal CECT images showing atrophic native bilateral kidneys (Thin white arrows) with transplanted kidney in RIF (Block white arrow). Fig 4 Arterial and Venous phase CECT axial images showing swirling appearance of SMV (Block white arrow) around SMA (Thin white arrow) giving rise to ‘whirl pool’ sign. Axial CECT image showing inverted relation of SMV (Block white arrow) and SMA (Thin white arrow). Coronal CECT images showing atrophic native bilateral kidneys (Thin white arrows) with transplanted kidney in RIF (Block white arrow). Despite all this, no significant bowel obstruction was present. Bowel loops showed normal contrast enhancement. No evidence of perforation, ischemia/necrosis were noted. No evidence of filling defect was noted in SMA, SMV or any other vessels. Patient underwent explorative laparotomy. Intra operative findings were: Donor kidney was present in right iliac fossa (pre peritoneal space).Cecum was present in right upper quadrant. About 180 degree clockwise rotation of midgut Duodenojenunal (DJ) flexure to the right over its mesentery along with jejunal loops on right side of abdomen was noted ( Figs. 6 and 7 ). SMA was present to the right of SMV and posterior to the duodenum. Ladd's band was present from duodenum to cecum ( Fig. 5 ). Intermesenteric bands were present and entire length of bowel was healthy. Fig. 5 Ladd's band from duodenum (Block white arrow). Fig 5 Fig. 6 DJ flexure to right of abdomen(Block white arrow). Fig 6 Fig. 7 Jejunal loops were noted and taken out from right side of abdomen (Block white arrow). Fig 7 Ladd's band from duodenum (Block white arrow). DJ flexure to right of abdomen(Block white arrow). Jejunal loops were noted and taken out from right side of abdomen (Block white arrow). Operative Procedure: About 180 degree counterclockwise rotation of bowel was done. Ladd's band was divided. Intermesenteric bands were divided and appendectomy was done. Small bowel was placed on right and left sided colon was placed over midline. Following 5 days after surgery, patient was discharged being symptoms free.