The true incidence of intestinal rotational disorders is unknown, although a report indicates that the ratio is approximately 0.2–1% of the population and that patients present symptomatically at a rate of 1 in 2500 . This condition is the result of an error during the embryonic period. The classification of these anomalies is divided into nonrotation, malrotation, incomplete rotation, paraduodenal hernia, and reverse rotation . Nonrotation is characterized by the duodenum traveling descending straight down to the right side of the SMA and the small intestine occupying the right side of the abdominal cavity and the large intestine located on the left side. Incomplete rotation or malrotation causes duodenal obstruction due to the formation of Ladd’s bands and the lack of duodenal loop rotation. This condition can lead to catastrophic midgut volvulus. Paraduodenal hernia is caused by failure of the 180° counterclockwise rotation of the midgut. The small intestine herniates between the ascending mesocolon and the retroperitoneum. Reversed rotation presents as the transverse colon located inferior to the duodenum and causes partial mesenteric arterial, venous, and lymphatic obstruction.
Abnormal rotation of the intestine tends to be discussed as a pediatric disease; however, adult patients suffer from this condition with either acute or chronic symptoms . Acute symptoms are caused by sudden obstruction and ischemic changes in the intestine, as in our case. Chronic symptoms are not specific, such as abdominal pain, vomiting, and diarrhea, and can last several years [4, 7, 17, 18]. The diagnosis of nonrotation in adults is not easy before the appearance of acute symptoms of obstruction. This is because patients usually develop without any symptoms or with mild chronic symptoms, and the number of cases is too small to identify [7, 19]. Diagnosis is mainly conducted with CT scan, upper gastrointestinal examination, or incidental surgical findings . However, radiographic examination is limited to diagnosing the anomaly of the rotation due to false positives and negatives [17, 20, 21]. Operative findings are vital for the final diagnoses of an abnormality. In our case, the patient showed acute symptoms, and the CT findings suggested the possibility of volvulus and nonrotation [17, 22, 23]. Finally, the operative findings confirmed that she had nonrotation with volvulus.
Colonic volvulus is the condition of bowel torsion around its own mesentery and is the third leading cause of large intestine obstruction . Intestinal volvulus patients tend to have a long redundant colonic segment and elongated mesentery with a narrow base [24, 25]. These anatomical characteristics are either congenital or acquired. One of the congenital causes is the anomaly of intestinal rotation [20, 26, 27]. This anomaly presents as a nonfixed colon and narrowed stalk formation with Ladd’s bands or mesentery adhesions. In our opinion, in cases of adult nonrotation patients, very loose volvulus intermittently occurs with light abdominal symptoms such as pain and vomiting. Loose volvulus and highly mobilized mesentery may cause friction and inflammation at the mesentery. Inflammation leads to the formation of fibrous adhesions at the mesentery and narrows the stalk. Adhesions play a role to serve as an axis in acute severe volvulus at any age. Consequently, once the volvulus attack due to a congenital intestinal rotation anomaly occurs, surgical resection of the involved intestine is the primary indication for radical surgery for treatment and prevention of recurrence. The surgical procedure should be noted along with Ladd’s procedure [28, 29]. First, reduction of the volvulus is required. Second, any fixed band between the cecum or ascending colon and abdominal wall or the duodenum should be dissected to widen the stalk of the mesentery. Third, the adhesion around the duodenum should be detached to mobilize the proximal jejunum to the right upper quadrant. Forth, the involved segment should be removed, and the anastomotic site should be located far from the duodenum to avoid shortening the mesentery stalk, which may lead to further volvulus. Finally, the bowel should be placed in a nonrotation position with appendectomy. There are several reports that indicate a second volvulus attack after Ladd’s procedure in infants for midgut volvulus . This supports our rare case in which an appropriate surgical procedure was performed for volvulus with nonrotation, but volvulus recurrence occurred. Hence, what gastrointestinal surgeons should know is that the intestinal rotation anomaly can suddenly affect adult patients and lead to fatal volvulus, and volvulus recurrence may occur even several years after surgery.