Subacute Small Bowel Obstruction in a 50-Year-Old Woman With Complete Intestinal Malrotation: A Case Report

Intestinal malrotation is a congenital anomaly resulting from the failure of the midgut to undergo its normal 270° counterclockwise rotation during embryological development. While the vast majority of cases are seen in neonates, adult presentation is exceptionally rare and often presents with vague abdominal complaints, leading to significant diagnostic delays. A 50-year-old woman presented with diffuse, colicky abdominal pain and recurrent bilious vomiting for three days. Vital signs revealed hypertension (170/100 mmHg) and tachycardia (107 bpm). The physical examination revealed a soft, but diffusely tender, abdomen. Plain abdominal radiograph revealed dilated bowel loops consistent with small bowel obstruction. Complete blood count and serum lactate were within normal limits. Contrast-enhanced CT confirmed complete intestinal malrotation with the small bowel located on the right side and the cecum located on the left side of the abdomen. Notably, the absence of the characteristic "whirl sign" indicated symptoms were due to transient duodenal compression by Ladd's bands rather than active midgut volvulus. An exploratory laparotomy was performed, revealing atypical anatomy with an unusual Ladd's band extending from the transverse colon to the right lateral parietal peritoneum, a variation from the classic cecal origin. A Ladd's procedure (adhesiolysis) was successfully performed along with prophylactic appendectomy and cecopexy to fixate the hypermobile cecum. The patient achieved complete recovery, tolerated diet well, and was discharged on Day 6 postoperatively. Notably, the patient's de novo hypertension persisted despite successful surgical correction, prompting investigation into causes of secondary hypertension, including endocrine disorders and renovascular disease. Adult intestinal malrotation is exceptionally rare but demands careful clinical attention. This case exemplifies an unusual anatomical variation with successful surgical management, emphasizing the importance of considering malrotation in the differential diagnosis of adult small bowel obstruction. It also highlights that coexisting medical conditions like hypertension require independent evaluation and management.