Incidental Intestinal Malrotation During Surgery for a Perforated Duodenal Ulcer in an Older Man: A Case Report
Mohammed Alsammani Abdalkareem Mahammed *
*Correspondence to: Mohammed Alsammani Abdalkareem Mahammed, General Surgery Unit, Khartoum North Teaching Hospital, Sudan.
Copyright.
© 2026 Mohammed Alsammani Abdalkareem Mahammed, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 01 October 2026
Published: 19 October 2026
DOI: https://doi.org/10.5281/zenodo.23470277
Abstract
Background: Intestinal malrotation is a congenital abnormality of intestinal rotation and fixation that may remain unrecognized until adulthood. It may be discovered during an operation for an unrelated abdominal condition.
Case presentation: A 70-year-old man presented with sudden severe epigastric pain, bilious vomiting, abdominal tenderness, guarding, and rigidity. He reported longstanding constipation, dyspeptic symptoms, and regular NSAID use. An X-ray showed free air under the right hemidiaphragm. Laparotomy on 20 February 2020 identified a 5 mm anterior perforation of the first part of the duodenum, with inflammation and bilious peritoneal contamination. An omental (Graham) patch repair was performed. Malrotation was discovered incidentally, with abnormal bowel positions, a narrow mesenteric base, and Ladd’s bands. It was not corrected because it was unrelated to the operative indication and consent had not been obtained. Helicobacter pylori testing was positive, and eradication therapy was commenced. Bowel function and oral intake resumed within 72 hours. The patient was discharged on postoperative day 5 and had no complaints at review 10 days after surgery. He was counselled and referred for specialist assessment of the malrotation.
Conclusion: This case illustrates incidental recognition of intestinal malrotation in an older man undergoing surgery for a perforated duodenal ulcer. The ulcer perforation was the reason for surgery. The coexistence of malrotation does not establish that it caused the ulcer or the presenting symptoms.
Keywords: intestinal malrotation; incidental finding; perforated duodenal ulcer; pneumoperitoneum; older adult; case report.
Introduction
Intestinal malrotation encompasses abnormalities of the position and fixation of the bowel arising during development. Although often associated with infancy, it can be diagnosed much later. In a retrospective series of 170 patients, Nehra and Goldstein found that 48% were adults. Abdominal pain was the most frequent adult complaint, and almost one third of adults had experienced symptoms for years before diagnosis [1]. These findings describe a selected clinical population rather than the prevalence of malrotation in the general population.
The clinical significance of malrotation depends on its anatomy and associated complications. Abnormal peritoneal attachments can obstruct the duodenum, while a narrow mesenteric attachment can predispose to volvulus [4]. However, malrotation may also be discovered incidentally during an operation for another condition. Its presence should be distinguished from the pathology responsible for the acute presentation.
This report describes incidental intestinal malrotation in a 70-year-old man operated on for a perforated duodenal ulcer. The acute presentation consisted of sudden severe upper abdominal pain, vomiting, abdominal tenderness, and subdiaphragmatic free air. The report focuses on the recognition and documentation of an unexpected intestinal anatomical abnormality during surgery for ulcer perforation.
Case Presentation
Patient information and clinical findings
A 70-year-old man presented with sudden severe epigastric pain and bilious vomiting beginning within the preceding 24 hours. He reported dyspeptic symptoms and regular NSAID use for knee osteoarthritis, with no previous abdominal surgery. He had experienced constipation for several years and used self-administered rectal water irrigation through a hose to facilitate bowel evacuation.
On examination, his blood pressure was 103/65 mmHg and pulse rate was 107 beats/min; he was afebrile. The abdomen was tender over the epigastrium and lower abdomen, with guarding and rigidity.
Laboratory investigations
The dated complete blood count showed a white blood cell count of 6.9 × 10³/µL, hemoglobin of 14.7 g/dL, hematocrit of 45.4%, and platelets of 208 × 10³/µL. The neutrophil percentage was 89.1%, with an absolute neutrophil count of 6.2 × 10³/µL. Serum amylase was 114.53 U/L against a laboratory upper limit of 85 U/L; lipase was 65.9 U/L against a reference interval of 13–60 U/L. Urea, creatinine, sodium, and potassium were within the intervals printed on that report (Table 1).
Imaging and diagnostic assessment
An X-ray showed free air under the right hemidiaphragm, supporting the diagnosis of a perforated viscus. The available radiographs were dated 20 February 2020. Intestinal malrotation was identified during surgery rather than diagnosed radiologically before the operation.
Operative findings and treatment
Exploratory laparotomy was performed on 20 February 2020 for a perforated duodenal ulcer. A 5 mm perforation was identified on the anterior wall of the first part of the duodenum, with surrounding inflammation and bilious contamination of the peritoneal cavity. The perforation was repaired with an omental (Graham) patch. Intestinal malrotation was identified incidentally during exploration. The duodenojejunal junction lay to the right of the midline, and the small bowel was predominantly right-sided. The caecum was near the midline at approximately the level of the umbilicus, while the large bowel followed an abnormal W-shaped distribution. A narrow mesenteric base and congenital peritoneal (Ladd’s) bands were identified (Figures 1 and 2).
No surgical correction of the malrotation was undertaken because it was unrelated to the indication for surgery and consent for its correction had not been obtained.
Postoperative course and follow up
The patient tested positive for Helicobacter pylori and was commenced on eradication therapy. Bowel function returned and oral intake resumed within 72 hours of surgery. No postoperative complications were reported. The patient was discharged home in good clinical condition on postoperative day 5.
At outpatient review 10 days after surgery, he reported no complaints and the surgical wound was well healed. He was counselled regarding the malrotation, its potential risks, and the option of corrective surgery. A referral letter was provided for evaluation and follow-up by a colorectal surgeon. Subsequent specialist assessment and longer-term outcomes were not reported.
Discussion
The central feature of this case is the incidental discovery of malrotation during surgery for a perforated duodenal ulcer. The sudden pain, vomiting, abdominal tenderness, and free air under the right hemidiaphragm formed the clinical presentation leading to surgery for ulcer perforation. The confirmed indication should remain distinct from the unexpected intestinal anatomy. There is no evidence in the available history that malrotation caused the ulcer or perforation.
Adult malrotation has a broad clinical spectrum. Nehra and Goldstein identified adults among 48% of 170 patients in their institutional series [1]. Neville and colleagues reviewed 194 adult cases, in which chronic symptoms were common and Ladd’s procedure was the most frequently reported operation [2]. This patient’s constipation had persisted for years and required rectal irrigation. Although relevant to his history, the coexistence of constipation and malrotation does not establish a causal relationship.
Xiong and colleagues reported a CT series of 332 adults, of whom 56.6% were asymptomatic. Their study assessed the duodenum, jejunum, caecum, and mesenteric vessels; most patients had a normal superior mesenteric artery–vein relationship [3]. These findings support assessment of the overall anatomical arrangement rather than reliance on a single sign. In this patient, the intraoperative bowel positions, narrow mesenteric base, and Ladd’s bands provided the anatomical basis for the diagnosis.
Congenital bands can compress the duodenum, while a narrow mesenteric base can predispose to volvulus [4]. Both features were reported in this patient, but neither establishes that malrotation caused the ulcer perforation. The surgeon left the malrotation uncorrected because it was unrelated to the operative indication and consent for correction had not been obtained. This was a case-specific decision. Counselling and subsequent referral provided an opportunity for specialist assessment and discussion of corrective surgery.
The radiographic free air and abdominal guarding and rigidity supported surgery for perforation. The WSES guidelines recommend operative treatment in perforated peptic ulcer with significant pneumoperitoneum, contrast extravasation, or signs of peritonitis, and emphasize timely surgery [6].
In this patient, a 5 mm perforation on the anterior wall of the first part of the duodenum was accompanied by surrounding inflammation and bilious peritoneal contamination. The perforation was repaired with an omental (Graham) patch. The patient tested positive for Helicobacter pylori and was commenced on eradication therapy. Recovery proceeded without reported complications. Regular NSAID use was relevant to the ulcer history, although the available information does not establish its cause.
The report documents ulcer perforation and incidental malrotation in the same patient, without establishing a causal association or the effectiveness of treatment for malrotation. Follow-up was limited to a review 10 days after surgery, and the outcome of the specialist referral is unavailable. The Helicobacter pylori testing method, eradication regimen, and confirmation of eradication were not reported, and other perioperative medication details remain unavailable. These limitations should be considered when interpreting the case, which is presented using the CARE framework [5].
Conclusion
Intestinal malrotation may remain unrecognized into older adulthood and be discovered during surgery for unrelated pathology. In this patient, a perforated duodenal ulcer was repaired with an omental (Graham) patch, while incidental malrotation was left uncorrected. Recovery was satisfactory during the reported short-term follow-up. The patient was counselled and referred for specialist assessment. The coexistence of longstanding constipation and malrotation does not establish causation.
Declarations
Consent for publication: Written informed consent was obtained from the patient for publication of this case report and the clinical photographs.
Ethics: The supplied institutional determination from Khartoum North Teaching Hospital, dated 28 March 2020, records that formal Research Ethics Committee review was not required for this retrospective single-patient case report under institutional policy. The report involved no additional research intervention or alteration of clinical management for research purposes.
Conflict of Interest
The author declares no conflicts of interest related to the preparation and publication of this case report.
Author Contributions
The author identified the intestinal malrotation during intraoperative exploration, reviewed the patient’s clinical history and operative findings, conducted the literature review, and prepared the manuscript. The author reviewed and approved the final version of the manuscript and accepts responsibility for its content.
Funding:
No specific grant or financial support was received from any funding agency in the public, commercial, or not-for-profit sectors for the preparation or publication of this case report.
Patient Perspective
The patient expressed satisfaction with the surgical management and postoperative pain control. He was counselled about the anatomical abnormality, its potential risks, and the need for specialist assessment. He agreed to follow-up with the colorectal surgical team to discuss possible corrective surgery. A relationship between his chronic constipation and malrotation was discussed as a possibility rather than an established cause.
Reference