Whirlpool No More: A Case of Misdiagnosed Malrotation with Midgut Volvulus

Introduction: Adult intestinal malrotation with midgut volvulus is rare and most often diagnosed on abdominal imaging. Once the diagnosis is made, prompt surgical intervention is necessary. A finding suggestive of malrotation with midgut volvulus on abdominal imaging is the “whirlpool” sign where the superior mesenteric vein and superior mesenteric artery twist at the root of the abdominal mesentery. This sign was once thought to be pathognomonic, but recent studies have shown that it can be seen in asymptomatic patients. Case Report: A 20-year-old female presented to our emergency department with diffuse abdominal pain. Computed tomography demonstrated the “whirlpool” sign with a concern for malrotation with midgut volvulus. Surgical consultation was obtained and the patient was rushed to the operating room for an exploratory laparotomy. Normal mesenteric attachments were seen and no significant pathology was identified during the laparotomy. The patient was eventually diagnosed with gastritis and discharged in stable condition. Conclusion: Emergency physicians and surgeons alike should be cautious in confirming malrotation with midgut volvulus solely due to the “whirlpool” sign on abdominal imaging. Premature diagnostic closure can lead to unnecessary procedures and interventions for patients as in the case we report here.

Intestinal malrotation with solitary jejunal diverticulum presenting as midgut volvulus in an adult: an unusual presentation

Intestinal malrotation with midgut volvulus presenting in adults is a rare entity, and association with jejunal diverticulum is rarer still. Herein, we report and review such a case of malrotation and volvulus, associated with intestinal band adhesions and a solitary jejunal diverticulum. This 67 years old gentleman had presented with complaints of intermittent abdominal pain for past several years. Imaging of the abdomen revealed twisting of superior mesenteric artery and vein, evidence of midgut volvulus and intestinal malrotation with “whirlpool sign”. Laparotomy revealed a midgut volvulus, extensive adhesions involving the root of the mesentery and a jejunal diverticulum. Adhesiolysis was performed, untwisting of the bowel was done and the jejunal diverticulum was resected. Post-operative period was uneventful. This case is being reported on account of its extreme rarity.

Sustaining viability in a pre-gangrenous bowel with midgut volvulus

Midgut volvulus is a condition peculiar to neonates having acute abdomen. The condition is anticipated in any neonate having bilious vomitus and inability to pass stools. This being a surgical emergency does not sanction any time-consuming radiological procedures, thus, history and the clinical picture are sufficient to warrant surgical exploration. A sick neonate in the 2nd week of life presented with all signs and symptoms of midgut volvulus for which he was explored. Exploration gave the outlook of a necrotic midgut along its entire length. No haste was made in resection as it had a fatal prognosis for survival, instead, watchful waiting opted after necessary measures were taken to allow for the resumption of perfusion. Not only the baby survived to undergo a relook laparotomy showing marked improvement but also showed improvement in lab values and started passing stool and tolerating orally after a wait of three weeks post 1st laparotomy. Midgut volvulus leading to seemingly necrotic intestine should be given due consideration by relook surgery. The alternative would be total resection followed by short bowel syndrome, need for an intestinal transplant while being on TPN. This approach gives an immense advantage by giving the gut a fair chance to restore its perfusion by gut rest after de-twisting.