Packed with pills - obstructing duodenal web in the setting of intestinal malrotation: A case report

BACKGROUND: The incidence of intestinal malrotation in adults has been reported to only be about 0.2%. Duodenal web as a cause of intestinal obstruction is rare, with an incidence of about 1:20000-1:40000. Furthermore, when described, these conditions are usually seen in early life and very infrequently in adulthood. CASE SUMMARY: We report a case of a middle-aged woman with intestinal malrotation who presented with a three-month history of right-sided abdominal pain, early satiety, and a 22-pound weight loss. Patient underwent an esophagogastroduodenoscopy, which demonstrated numerous retained pills in a deformed first portion of the duodenum, concerning for a partial gastric outlet obstruction. An upper gastrointestinal series showed marked distention of the proximal duodenum with retained debris and the presence of a windsock sign, increasing the suspicion of a duodenal web. The patient subsequently underwent surgical intervention where a duodenal web with two lumens was noted and resected, opening the duodenum. There were over 150 pill capsules that were removed. The patient is doing well after this intervention. CONCLUSION: Both intestinal malrotation and duodenal webs are infrequently encountered in the adult population. These pathologies can also present with nonspecific abdominal symptoms such as chronic abdominal pain and nausea. Hence, providers might not consider these pathologies in the differential for patients who present with vague symptoms which can lead to delay in management and increased mortality and morbidity.