Small Bowel Obstruction Secondary to Partial Malrotation of the Gut: A Case Report

This case report presents a unique clinical presentation of small bowel obstruction secondary to congenital partial malrotation of the gut in adults. Partial malrotation may have variable clinical presentations and this case highlights a constellation of patient history, radiographic signs, and operative findings leading to appropriate diagnosis and successful surgical management. A 56-year-old female patient presented with severe abdominal pain, nausea, and anorexia. She reported acute on chronic vague, intermittent cramping abdominal pain for approximately five months. Prior evaluations of her gastrointestinal symptoms did not reveal a clear etiology. On examination, the patient's vital signs were within normal limits and the abdominal exam was benign. Computed tomography (CT) of the abdomen and pelvis with IV contrast, obtained in the emergency department, was concerning for paraduodenal hernia but was also notable for the lack of a duodenal sweep. With the severity of abdominal pain being out of proportion to the physical exam and the aforementioned radiographic findings, we decided to proceed with diagnostic laparoscopy. Intraoperative findings included a Ladd band forming a potential space for the incarceration of the bowel, internal herniation of the partially reducible small bowel, and a narrow mesenteric base. A laparoscopic Ladd procedure was performed and the patient recovered without complications. Her chronic gastrointestinal complaints have abated since the operative intervention. This case underscores the importance of considering a rare diagnosis such as partial malrotation of the gut in adults presenting with acute on chronic abdominal pain, the key clinical features associated with this pathology, and its successful operative management. Furthermore, this case highlights the importance of early recognition and management to minimize the morbidity and mortality of devastating sequelae such as midgut volvulus and closed-loop obstruction.