Incidentally Detected Malrotation in a Case of Traumatic Gastric Perforation

Introduction: Intestinal malrotation is defined as intestinal nonrotation or incomplete rotation around superior mesenteric artery and involving anomalies of intestinal fixation. The incidence of intestinal malrotation is estimated to be around 1 in 6000 live births. Most patients remain asymptomatic and are incidentally detected at a surgical procedure or during autopsy. Adult presentation accounts for 0.2 to 0.5% of all cases, of which only 15% present with midgut volvulus.

Case Presentation: A 36 year old male presented to casualty with blunt trauma to abdomen 2 days back. On examination, patient had BP 90/60mmHg and pulse 130bpm, respiratory rate of 32 breaths per minute and saturation of 78% in room air; with per-abdomen examination showing diffuse tenderness with guarding and rigidity and X-ray chest showing gas under diaphragm; which suggested perforation peritonitis with septic shock for which he underwent emergency laparotomy and there were presence of 4x4 cm size anterior gastric perforation with presence of transverse colon going below stomach and jejunum with small bowel loops present on the right . Antrocolic isoperistaltic gastrojejunostomy was done. Postoperative period uneventful with patient discharged on POD 10 with him passing stool and on normal oral diet.

Conclusion: Intestinal malrotation is a rare developmental anomaly of embryonic gut. The most severe presentation is malrotation with bowel volvulus. 30% cases occur in the 1st month of life, 60% by one year of age, and over 75% percent by age of five. Adult presentation is only 0.2 to 0.5% , of which 15% present with midgut volvulus. Most common presentation is bilious vomiting in infants while in older children, there is presence of chronic and intermittent abdominal pain. The role of additional surgery especially in asymptomatic patients with malrotation is debated. Delayed presentation of malrotation shows varied symptoms. It needs high index of suspicion with relevant investigations (USG and CT) to avoid any further complications.