Unusual presentation of obstructive colonic ileus in a patient with intestinal malrotation: A diagnostic challenge

P. Reynaud, C. Sénéchaud, N. Chapuis Department of Surgery, Hospital of jura bernois, St-Imier, Switzerland

Abdominal cramping start appearing and pain became stronger. An explorative laparotomy was performed. A hugely dilated cecum of 20 cm of diameter full of stool was discovered. Anatomically, the small intestine was entirely on the ride side, and the right colon was situated medially in the abdomen. Through colonic inspection, we discovered an obstructive intraluminal colonic lesion situated at the left angle of the proximal part of the descendent colon. A left hemicolectomy with primary anastomosis was performed. Pathology finding was an adenocarcinoma.

Case presentation: A 44 year old women was referred to our Emergency Service for a progressive diffuse mild abdominal pain and bloating. No nausea nor mictional disorders where reported, stool where rare but gas still passed. Physical exam showed a distended abdomen with a tender sub umbilical mass giving the appearance of a 6 month pregnant women. Her right iliac fossa showed a scar for an appendectomy during childhood. Laboratory investigations results were normal, pregnancy test negative.

Fig. 1 and fig. 2 : Dilated cecum respectively at CT scan and in operation room during laparotomy.

Radiological X-ray and CT scan was first interpreted as a colic distension with an important coprostasis. Initial diagnosis was a giant fecal impaction. Several rectal enemas where done but no evacuation was noted. Rectoscopy exam showed an empty rectum. A gastrografin enema showed a normal progression of the product but a 2nd CT scan showed the persistence of this same pelvic opacity.

Fig. 3: X-ray showing colonic dilatation with an cecum and ascending colon centred on the midline. Fig. 4: Illustration showing the type of intestinal malrotation of our patient (*) site of adenocarcinoma, (**) resection margins.

Background: Intestinal malrotation is a congenital anatomical anomaly that results from an abnormal rotation of the midgut. Generally seen in paediatric patient, adulthood incidence is estimated to be between 0.0001% and 0.19%.(1)

Conclusion: The type of malrotation encountered in this case is typically an adulthood non pathogenic form and usually remain undiagnosed. Even if adulthood presentation is rare, intestinal malrotation may present a diagnostic trap. An increased awareness of this entity and an understanding of its varied presentation may help achieve faster diagnosis.

References: (1)Wang C, Welch C: Anomalies of intestinal rotation in adolescents and adults. Surgery 1963