Adult Intestinal Malrotation in a Non-Paediatric Hospital in Trinidad: A Case Report and Literature Review

Intestinal malrotation (IM) is a congenital aberrancy of midgut rotation during development, which manifests among neonates more than adults. Older reports have estimated an incidence of one in 6,000 live births, which is now as high as one in 500. This congenital anomaly is generally indolent in the adult population. Recent literature research has failed to reveal any publications regarding the incidence within a Caribbean population. This paper aims to discuss the isolated case of a patient with this rare condition, who presented to a non-paediatric centre in Trinidad. This case highlights the implications of the initial radiological interpretation in conjunction with perioperative and intraoperative decision making. An 18-year-old male presented with a one-day history of abdominal pain, radiating to the epigastrium with nausea and excessive vomiting. Vital signs and blood investigations were normal. Initial CT scan results were interpreted as an internal hernia, which was surgically managed as such. Repeat imaging and a second laparotomy were required to correctly diagnose and perform the appropriate Ladd procedure. IM occurs due to the arrest of rotation of the midgut during fetal maturation. The incomplete rotation variant was seen in this case and is predominantly responsible for the symptomatology and morbidity associated with adult intestinal malrotation (AIM). Stringer has classified these anomalies based on the stage of embryonic development that is disrupted. CT helps with diagnostics in 97.5% of cases. This case highlights the implication of incorrect assessment on imaging and how it may misguide the interpretation of the findings at laparotomy leading to inappropriate surgical procedures. As many as 20% of cases undergo surgery without adult intussusception diagnosed. The incidence of IM seems to have increased but is scarcely encountered in the adult setting. When encountering this condition at a low-volume centre in the Caribbean, the adult specialist may be blindsided, and unknowingly underprepared without a high index of suspicion. Diagnosis at childhood should be discussed with the family and again with the patient on approaching adulthood. Patient education may help with the surgical assessment.