Malrotation with Midgut Volvulus Beyond Infancy Requiring an Extensive Ileal Resection: A Case Report

Abstract

Midgut malrotation is a congenital anomaly resulting from abnormal rotation and fixation of the midgut during embryogenesis. It can be complicated by volvulus and intestinal obstruction. It rarely presents after the first year of life, which makes it a diagnostic challenge. A 5-year-old Arab female presented to the emergency department (July 2024) with repetitive frothy vomiting and diffuse abdominal pain. Laboratory findings showed leukocytosis, metabolic acidosis (pH 7.04, 13 HCO3), and deteriorating renal and liver functions.  Abdominal x-ray and ultrasound suggested intestinal obstruction (the presence of distended bowel loops) without a definitive source for the obstruction. An upper gastrointestinal study wasn't done due to continuous vomiting and worsening acidosis. Resuscitation and immediate surgical exploration to identify and treat the source of obstruction were done on the same day. It revealed an intestinal malrotation with distal jejunal volvulus and borderline ischemia of the ileum. First operation included detorsion of the volvulus, excision of the gangrenous segment (a 6cm segment located 6cm proximal to the ileocecal valve) with anastomosis of the remaining gut, and appendectomy. Postoperatively, the patient improved progressively for a week, but then developed an acute abdominal distension with tenderness, necessitating a relaparotomy with a near-total resection of the ileum (150 cm) and stoma formation (double-barreled ileostomy and jejunostomy). Finally, the stoma was closed, and the patient had a jejunoileal anastomosis. The patient recovered well and was discharged on a regular, pureed diet (weight 15.6 kg, passing soft stool twice/day) after 83 days of inpatient observation.