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Gut malrotation and mesenteric thrombosis in adult: A rare presentation of chronic abdominal symptoms

A 54-years-old woman sought a gastroenterological consultation reporting a 10-year history of progressive abdominal pain, distension, and diarrhea, accompanied in the last year by a weight loss of 12 kg. Abdominal examination and laboratory tests were normal. A computed tomography (CT) scan showed intestinal malrotation with “whirlpool sign,” associated with arterial and venous mesenteric thrombosis with collateral vascularization (Figure 1). A mesenteric arteriography demonstrated vessel obstruction at the level of superior mesenteric artery, combined with pronounced collateral vascularization (Figure 2). The symptoms had completely improved with a fractionated diet. The Ladd's procedure was indicated. However, the patient's option was to maintain clinical treatment. Intestinal malrotation is more frequent in males (2:1) and the presentation in adults ranges from 0.2% to 0.5%. Among symptomatic patients, the presentation can be acute, with intestinal obstruction or ischemia, or chronic, with intermittent abdominal pain, early satiety, and vomiting. The diagnosis is often made by CT scan, in which the pathognomonic findings are midgut volvulus combined with the “whirlpool sign” of the mesentery and superior mesenteric vein (SMV) wrapped around the superior mesenteric artery (SMA). However, chronic obstruction of SMV and SMA in adults is a rare presentation of the gut malrotation. In this condition, abdominal pain, weight loss, and diarrhea are the most common presentations. Ladd's procedure is the gold standard surgical treatment, consisting of the duodenum and right colon mobilization, appendectomy, and section of the