Adult intestinal malrotation with duodenal obstruction secondary to Ladd’s band

A 48-year-old male patient presented with complaint of bilious vomiting and acute onset abdominal pain since 2 days. No relevant past medical or surgical history. Upper GI endoscopy revealed dilated proximal duodenal loops with bile juice seen as content. Endoscope was unable to be negotiated beyond 2^nd part of duodenum. Contrast enhanced CT abdomen and pelvis was advised for further evaluation.

Plain and both oral and IV contrast-enhanced CT abdomen and pelvis was performed on Multi-slice CT scan. 110 ml of non-ionic contrast was injected with bolus tracking @4.5ml/sec. Scan revealed dilated Proximal duodenal loops with abrupt narrowing distal to 2^nd part of duodenum. Small bowel loops were seen on the right side of abdomen. Cecum, appendix and ascending colon were present on the left side of abdomen along with descending colon loops. Vertical orientation of SMA-SMV relationship was observed, without presence of Whirlpool or swirl sign. No obvious abnormal wall thickening or mass lesion was seen.

Imaging findings were suggestive of Intestinal Malrotation with Duodenal Obstruction secondary to Ladd’s Band. Ladd’s Procedure was advised.

Ladd’s procedure was performed by midline laparotomy. Ladd’s band was identified and was released.

Intestinal malrotation are rarely found in adults. It is estimated that more than 90% of patients with intestinal malrotation will present in the first 12 months of life [1]. However, some children may escape this period if they were asymptomatic or only had vague abdominal symptoms which were misinterpreted for another cause [2]. Adult presentation of midgut malrotation may present in two distinct patterns: acute and chronic [3]. In our case, patient presented with acute onset of symptoms in the form of abdominal pain and vomiting.

Gold standard diagnosis in adults is usually with cross-sectional imaging with oral and intravenous contrast CT [4]. Imaging findings include variable SMA-SMV relationship with malpositioned intestinal loops, whirlpool sign in cases of volvulus and dilated proximal duodenum.

Surgical management of intestinal malrotation at any age is by Ladd’s procedure [5]. This procedure was first described by William Ladd in 1936.

Most adult patients have a resolution of their symptoms of intestinal malrotation after Ladd’s procedure [6].

Ladd’s procedure can be performed through midline laparotomy or laparoscopically. Usually, if an adult patient presents acutely, it is reasonable to proceed to midline laparotomy [5]. Laparoscopy appears to be safe and effective when performed by experienced laparoscopic surgeons and usually in the absence of volvulus [3]. 

Ladd’s procedure results in excellent prognosis with complete resolution of symptoms as in our case.

Teaching Point

Intestinal mal-rotation although rare in adults should be considered as a possible cause of acute abdomen pain with vomiting. CT abdomen and pelvis is the gold standard investigation for diagnosis in such patients. Findings of dilated proximal duodenal loops with mal-positioned bowel loops are characteristic features. Ladd’s procedure should be advised and release of Ladd’s band improves the clinical symptoms and prevents further complications of bowel ischemia. An accurate diagnosis helps in both management and prognosis.

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