duplication of the alimentary tract is an important surgical condition , which includes a wide variety of mass lesions .
we encountered a patient who presented with perforation of the duplication , which was associated with malrotation with midgut volvulus .
being an extremely uncommon surgical emergency , it is being presented with a brief review of the relevant literature .
a 4-year - old male child was referred to us for complaint of pain in abdomen .
however , there was occasional history of abdominal pain , which was relieved by medication . on examination , his abdomen was distended , but it was non - tender .
a computerized tomography ( ct ) scan of abdomen was advised for confirmation of the diagnosis . on next day , just after ct abdomen , the patient suddenly developed severe abdominal pain .
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 .
ladd 's bands were also present . the peritoneal cavity was grossly contaminated with fecal fluid .
the perforation was at the mesenteric side , and it was associated with a soft mesenteric mass communicating with the normal bowel .
the perforation was just at the junction of the mesenteric mass and the normal bowel [ figure 1 ] .
the other thumb forceps is in the perforated duplication after 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 2 and 3 ] .
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 .
( a ) duplication cyst , ( b ) junction of duplication and normal bowel , and it was the site of perforation , ( c ) normal ileum , ( d ) duplicated ileum reaching up to cecum , and ( e ) cecum and probable site of duplication termination in the postoperative period , there was wound infection with superficial wound dehiscence .
the patient was discharged after 3 weeks with proper follow - up advise . during the follow - up
these abnormalities include developmental obstructive defects of the small intestine , anomalies of rotation and fixation , intestinal duplications , etc .
duplications of the alimentary tract are rare congenital malformations and may occur anywhere in the intestinal tract .
the initial suspicion , on the basis of usg , was of some cystic mass lesion compressing the upper small bowel .
the ct plates , reviewed later on , also showed twisting of mesenteric vessels suggestive of malrotation .
probably the perforation of the duplication was not spontaneous ; it may be because of the volvulus and resultant ischemia of the wall .
as malrotation with midgut volvulus is always a surgical emergency , and perforated duplication is also a surgical emergency , a combination of the two entities is definitely a surgical emergency , which needs immediate intervention .
the ideal treatment would have been a ladd 's procedure , along with resection of the complete duplication .
this was , however , not possible due to the poor general condition of the patient and large length of the duplication , which may had led to extensive resection of the bowel .
the association of duplication of small bowel and malrotation , though described in the literature , is a rare one .
. to conclude , this being one of a very rare combination of two pediatric surgical emergencies ; needs proper surgical and postoperative management .
the exact preoperative diagnosis may be difficult , but a high degree of suspicion is warranted .
 duplication of the alimentary tract is an important surgical condition . 
 it may occur anywhere in the gastrointestinal tract . 
 an important complication of this entity is perforation of the normal or abnormal gut . 
 malrotation with midgut volvulus can be a surgical emergency . 
 we present a patient , who presented as malrotation with midgut volvulus associated with perforated ileal duplication . 
 the patient was successfully managed . 
INTRODUCTION
CASE REPORT
DISCUSSION