Via Research Recognition Day 2024 VCOM-Carolinas

Clinical Case-Based Reports

An Unusual Case of Midgut Volvulus in an Adult Chirag Lodha, OMS-III, Mohamed Abutineh, OMS-III, Chinedum Nkemakolam, OMS-III, Edward Murphy, MD Cleveland Clinic Indian River Hospital, Vero Beach, FL

Introduction

Results

Conclusions

• 72 year old female comes to the Emergency Department (ED) with severe abdominal pain, nausea, and vomiting. • CT of the abdomen showed a midgut volvulus with whirled mesentery (whirlpool sign). • She was taken to emergent surgery, at which point there was no evidence of volvulus, and the bowel was in its correct position without any evidence of a causative factor for her volvulus. • She recovered well with normal bowel function and was discharged to her home. • Two months later, she presented once again to the ED with nausea and vomiting. • X-ray showed a small bowel obstruction with a component of midgut volvulus. • She was taken to surgery once again, where her volvulus was clearly visible. • She underwent lysis of adhesions and was noted to have a very mobile bowel as well as a longer superior mesenteric artery (SMA) pedicle. • She was discharged a few days after her surgery in stable condition to her home. • Since then, she has had no issues regarding her bowel function and has not suffered from any additional episodes of nausea, vomiting, or abdominal pain. • Midgut volvulus is commonly due to embryologic remnants of intestinal rotation. • Primarily a diagnosis seen in young children, adults comprise of 0.2-0.5% of midgut volvulus cases. • Most cases of volvulus in adults present asymptomatically. • Symptomatic cases present with vague signs, such as a chronic abdominal pain. • Prompt diagnosis of midgut volvulus is vital, as it can lead to massive bowel and ischemia if not corrected promptly. • A recurrent midgut volvulus is especially rare and should raise suspicion for additional factors that could be contributing to a midgut volvulus. Report of Case

• Midgut volvulus is a rare diagnosis in the adult population, which makes a case of recurrence even more unique. • Risk factors include prior abdominal surgeries, intestinal malrotation, and mesenteric laxity. • Management typically involves either a lysis of adhesions performed either via laparotomy or laparoscopically. • An accurate diagnosis is crucial for timely management and to decrease the risk of bowel ischemia. • Due to most adult patients being asymptomatic, a midgut volvulus can frequently be overlooked as a potential diagnosis in this patient population.

Figure 1 . CT abdomen during 1st visit showing whirlpool sign

Figure 2. X-ray abdomen during 2nd visit showing "coffee bean" sign

References

1. Bernstein, S. M., & Russ, P. D. (1998). Midgut volvulus: a rare cause of acute abdomen in an adult patient. AJR. American journal of roentgenology , 171 (3), 639-641. 2. Butterworth, W. A., & Butterworth, J. W. (2018). An adult presentation of midgut volvulus secondary to intestinal malrotation: A case report and literature review. International journal of surgery case reports , 50 , 46-49. 3. Ferreira, M. S., Simões, J., Folgado, A., Carlos, S., Carvalho, N., Santos, F., & Costa, P. M. (2020). Recurrent midgut volvulus in an adult patient — the case for pexy? A case report and review of the literature. International Journal of Surgery Case Reports , 66 , 91-95. 4. Sheikh, F., Balarajah, V., & Ayantunde, A. A. (2013). Recurrent intestinal volvulus in midgut malrotation causing acute bowel obstruction: A case report. World Journal of Gastrointestinal Surgery , 5 (3), 43.

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2024 Research Recognition Day