Non-rotation of the Intestine: A Rare and Unexpected Cause of Bowel Obstruction in an Octogenarian

An 85-year-old male presented to our emergency department with a three-day history of nausea, vomiting, diffuse lower abdominal pain, and diarrhea. His last bowel movement was in the morning prior to the evaluation. Physical exam demonstrated diffuse abdominal tenderness without peritoneal signs. CT scanning of the abdomen and pelvis (without contrast) was concerning for low-grade obstruction. He was observed for the next 24 hours. Although some improvement occurred, an elevated serum lactate and deteriorating renal function resulted in the decision to perform diagnostic laparoscopy to assess the presumed small bowel obstruction. Operative findings suggested the possibility of malrotation, so an open laparotomy was performed. This operation demonstrated the presence of Ladd's bands with torsion of the small bowel. The Ladd's bands were lysed, the detorsed small bowel was then placed on the right side of the abdomen, and the colon was placed on the left side with the cecum in the left upper quadrant, allowing broadening of the mesentery. The appendix was also removed in accordance with Ladd's procedure. The patient tolerated the operation well but required extended postoperative care to manage his renal failure and new-onset atrial fibrillation. The patient was discharged on the 10th postoperative day and followed for the next year and a half without subsequent problems.