A delayed diagnosis of incomplete intestinal rotation in a 4-year-old: A case report of atypical gastrointestinal malrotation, diagnostic and management challenges in a resource-constrained health facility

Abstract

BACKGROUND: Gastrointestinal malrotation is a rare congenital anomaly caused by incomplete midgut rotation during embryogenesis. It affects approximately 1 in 500 live births, with symptomatic cases seen in about 1 in 6000 children. Although over 75 % are diagnosed in the neonatal period, older children may present with nonspecific symptoms. CASE PRESENTATION: We report a 4-year-old male with a two-year history of recurrent bilious vomiting and intermittent abdominal distension. Initially misdiagnosed as gastritis and treated with proton pump inhibitors without improvement, the patient underwent an abdominal ultrasound that revealed a normal mesenteric vessel but an abnormal duodenal position. The third part of the duodenum (D3) was located to the right of the superior mesenteric vessels instead of posteriorly, and localized dilation of the proximal duodenum and stomach suggested intestinal malrotation. DISCUSSION: Surgical exploration via a supra-umbilical transverse incision confirmed incomplete midgut rotation. The duodenojejunal junction was abnormally positioned in a mid-right lateral orientation, and the cecum was found in the right upper anterior quadrant. Significant Ladd's bands were compressing the anterior duodenum, causing dilation, while the mesenteric base was markedly narrowed and shortened, increasing volvulus risk. A standard Ladd's procedure was performed, dividing the bands and broadening the mesenteric base. Prophylactic appendectomy was omitted because the appendix appeared normal, the corrected anatomy minimized future diagnostic confusion, and the risk of appendicitis was low. CONCLUSION: This case highlights the diagnostic value of ultrasound in older children with gastrointestinal symptoms and underscores early recognition and prompt surgical intervention. These findings greatly impact clinical decision-making and management.