Malrotation with midgut volvulus associated with perforated ileal duplication
A 4-year-old male child was referred to us for complaint of pain in abdomen. On enquiry, there was intermittent history of bilious vomiting since infancy. There was no previous history as regard to abdominal distension. However, there was occasional history of abdominal pain, which was relieved by medication. On examination, his abdomen was distended, but it was non-tender. The weight of the patient was 9 kg. Thus he had failed to thrive. His ultrasound (USG) of abdomen suggested some fluid filled cystic spaces. A computerized tomography (CT) scan of abdomen was advised for confirmation of the diagnosis.\nOn next day, just after CT abdomen, the patient suddenly developed severe abdominal pain. X-ray abdomen showed pneumoperitoneum. Clinically the patient looked septic. His pulse rate was 130/min with a feeble pulse. An urgent laparotomy was planned. After initial stabilization, the patient was explored under general anesthesia. On exploration, we noticed malrotation of the gut, which was associated with two turns of midgut volvulus. The midgut did not have any evidence of ischemia or gangrene. It was complete malrotation having cecum in left hypochondrium and narrow mesentery. Ladd's bands were also present. The peritoneal cavity was grossly contaminated with fecal fluid. The perforation site was about one foot proximal to ileocecal region. The perforation was at the mesenteric side, and it was associated with a soft mesenteric mass communicating with the normal bowel. The mass was about 10 cm in length. The perforation was just at the junction of the mesenteric mass and the normal bowel [].\nAfter performing the Ladd's procedure, attention was placed towards the perforation. On attempting to resect the mesenteric mass, we noticed two lumens in the bowel distal to the perforation site and single lumen proximal to that [Figures and ]. The duplication appeared to be having all the layers of the bowel wall. When an attempt to ascertain the length of the duplication was made by inserting two Ryle's tube through the lumens, it was reaching up to ileocecal region. As the general condition of the patient was poor, complete resection of the bowel was not done, and a double barrel (triple barrel, to be more precise) was fashioned.\nIn the postoperative period, there was wound infection with superficial wound dehiscence. It was managed conservatively. The patient was discharged after 3 weeks with proper follow-up advise. During the follow-up, we had closed the ileostomy. As the duplication was reaching up to cecum, we had performed ileoascending anastomosis. The patient is fine.