MED-4. Adult malrotation mimicking pancreatic pathology.

Malrotation is an anomaly of fetal intestinal rotation and fixation that usually presents in the first month of life. Adult presentation is rare and difficult to diagnosis in the absence of specific physical findings and may be complicated by volvulus and intestinal necrosis. We present a case of surgically confirmed malrotation of the small bowel in an adult who presented with acute abdominal pain. 24-year-old female presented to emergency room with worsening abdominal pain since 5 days. Pain was diffuse, severe, cramping in nature radiating to back associated with nausea and several episodes of bilious vomiting. Her last bowel movement was 2 days back, was normal. She denied any history of pancreatitis, kidney stones, peptic ulcer disease or colitis. She had a normal vaginal delivery 1 year back and denies any surgeries. She also denied any alcohol, tobacco or drug use. She took hydrocodone for abdominal pain since 4 days. She has family history of hypertension and diabetes. Physical exam showed a well nourished female who appears to be in moderate distress. Blood pressure 140/92, pulse 132/min, respirations 16, temperature 98. Her abdomen was minimally distended on inspection. Normal bowel sounds were auscultated. Diffuse tenderness to palpation, exquisitely over left upper quadrant with no rebound tenderness or guarding. Her rectal exam is normal and her stool was hemoccult negative. Complete blood count and basic chemistry are with in normal limits. Lipase was 473, amylase 138, AST 94, and ALT 49. Abdominal x-ray showed no free air or air fluid levels. CT scan of the abdomen and pelvis reported gaseous distention of abdomen with no signs of obstruction. The patient was admitted and managed with nasogastric tube decompression, intravenous hydration and symptomatic medicines for suspected pancreatitis. In the next few days the patient continued to have abdominal pain, nausea and bilious vomiting. Esophagogastroduodenoscopy revealed normal mucosa with no ulceration. The patient refused upper and lower gastrointestinal series and continued to deteriorate with raise of lipase and amylase to 2829 and 480, respectively. On day 5, abdomen pain worsened, repeat CT scan of abdomen showed small bowel obstruction and midgut volvulus. Exploratory laparotomy revealed malrotation of the small bowel with cecum and appendix to the left of the lower quadrant and abdomen, with Ladds bands compressing the duodenum and proximal small bowel. Patient underwent Ladds procedure with cecopexy. Postoperatively, the patient did well and was discharged on postoperative day 3. Review of the initial abdominal CT scan revealed Whirl pool sign, the swirling appearance of bowel and mesentery twisted around superior mesenteric artery axis. Adult malrotation is a difficult diagnosis and requires high index of suspicion. Appropriate diagnostic studies and surgery may be life saving. CT scan findings of malrotation with midgut volvulus may be characteristic.

Pavan Manchikalapati, MD, Luis Zegada, MD, Randy Panther, MD, and Wick Many, Jr, MD.