A Twisted Presentation: Adult Intestinal Malrotation Complicated by Caecal Volvulus and Perforation.

Intestinal malrotation is a congenital anomaly caused by incomplete rotation and fixation of the midgut during embryological development. Although it is usually diagnosed in infancy, rare adult cases may present with acute intestinal obstruction or perforation. Cecal volvulus is an uncommon but potentially life-threatening complication of malrotation. We report a 35-year-old woman who presented with severe abdominal pain, progressive distension, and absolute constipation for two days. Clinical examination revealed generalized peritonitis with absent bowel sounds, and an erect radiograph demonstrated free gas beneath both hemidiaphragms, indicating hollow-viscus perforation. Because of generalised peritonitis mandating urgent operation, she proceeded directly to emergency laparotomy without cross-sectional imaging. Intraoperatively, a cecal volvulus was identified in association with intestinal malrotation and Ladd's bands, together with a single perforation on the anterior wall of the ascending colon. The involved cecum and ascending colon were markedly distended and venously congested from the closed-loop obstruction but showed no frank ischemia or gangrene, and bowel color improved after detorsion. Ladd's bands were divided, the volvulus detorsed, the perforation repaired primarily in two layers, and a defunctioning loop ileostomy fashioned. The patient had an otherwise uncomplicated postoperative recovery and was discharged on postoperative day seven. The loop ileostomy was reversed at three months, and at six months the patient was well, asymptomatic, and passing normal stool without evidence of recurrence. This report highlights the importance of considering congenital malrotation in adults presenting with an acute abdomen and discusses the rationale for bowel-preserving surgery when viability is retained.