malrotation of the midgut is an abnormality in embryological development of gastrointestinal tract . by the fourth intrauterine week
the gastrointestinal tract is in the form of an endoderm lined tube divided into fore , mid- and hindgut .
mid- and hindgut defined by their blood supply the superior and inferior mesenteric arteries respectively . by the fifth week of life the midgut begins a process of rapid enlargement , physiological herniation and rotation . with rapid expansion of liver and kidneys , expansion of the midgut intestinal loop
can not be contained within the abdominal cavity ; this results in temporary physiological midgut herniation through the umbilical cord with superior mesenteric artery forming the axis .
this process forms  c  of the duodenum and places it behind the superior mesenteric vessels .
hernial reduction occurs by week 10 with the jejunum reducing first and lying to the left and subsequent distal portions lying progressively to the right .
the ceacum descends from position in the right upper quadrant forming the descending colon with its mesentery gradually disappearing .
a 17-year - old male was seen in the emergency department with 10-year history of abdominal colic which is relieved by vomiting , along with dehydration .
there was no history of jaundice , fever , steatorrhea , or bleeding per rectum .
the patient had been treated with proton pump inhibitors , prokinetic agents by general practitioners , without any relief . his ultrasound examination and standing x - ray of abdomen
physical examination was normal except minimal abdominal tenderness in epigastric , right hypochondriac region along with mild dehydration .
his liver function tests , renal function tests , amylase , hemogram , and urinalysis were normal .
duodenum appeared connected to small intestine seen on right side giving a whirlpool appearance due to rotation of gut around the superior mesenteric artery .
superior mesenteric vein was seen on left of superior mesenteric artery [ figures 1a and b ] .
stomach and duodenum appear connected to small intestine seen on the right side giving a whirlpool appearance due to rotation of gut around the superior mesenteric artery .
superior mesenteric vein is seen on the left of superior mesenteric artery surgical referral was made ; he was treated with four - port laparoscopic ladd 's procedure .
the peritoneum to the right of the ascending colon and caecum was incised and the anteriorly situated bands were stripped to free the duodenum .
he was discharged within 2 days eating a normal diet and made a good postoperative recovery . at 3 months he was gaining weight and had no further vomiting .
midgut mal and nonrotation refers to failure in counter clockwise rotation of the midgut which results in misplacement of the duodeno 
jejunal junction to the right of the midline ; in addition the small bowel mesentery has narrow vertical posterior attachment which is prone to volvulus .
other anatomical abnormalities include peritoneal ( ladd 's ) bands running from the right colon to the lateral abdominal wall and an extensively mobile ceacum that fails to descend .
acute presentation is with volvulus of midgut or ileoceacum occurring most frequently in neonate with likelihood decreasing with age . in most of the reported cases of this presentation , patients present with bilious vomiting in the first month of life because of duodenal obstruction or a volvulus .
pathophysiology of these chronic symptoms may relate to the compressive effects of peritoneal bands running from ceacum and ascending colon to the right lateral wall .
the short mesentery allows the small bowel to twist around the narrowed sma pedicle to create a distinctive  whirlpool  appearance .
surgical management of intestinal malrotation was first described by ladd in 1936 and remains mainstay of management today .
it involves reduction of vovulus if present , division of abnormal peritoneal bands ( duodeno colic , dodenojejunal - ileocolic ) , and placement of the small bowel to the right of the abdomen and ceacum to the left .
increasingly laparoscopic ladd 's procedures are being performed and have been shown to be effective where there is no acute volvulus.[79 ] this minimally invasive approach allows for earlier oral intake and discharge from hospital .
 abnormalities in midgut rotation occur during the physiological herniation of midgut between the 5th and 10th week of gestation . 
 the most significant abnormality is narrow small bowel mesentery which is prone to volvulus . 
 this occurs most frequently in the neonatal period , less commonly midgut malrotation presents in adulthood with either acute volvulus or chronic abdominal symptoms . 
 it is the latter group that represents a diagnostic challenge . 
 we report a case of a 17-year - old male patient who presented with 10-year history of nonspecific gastro - intestinal symptoms . 
 after extensive investigation the patient was diagnosed with midgut malrotation following computed tomography of abdomen . 
 the patient was treated with a laparoscopic ladd 's procedure and at 3 months he was gaining weight and had stopped vomiting . 
 a laparoscopic ladd 's procedure is an acceptable alternative to the open technique in treating symptomatic malrotation in adults . 
 midgut malrotation is a rare congenital anomaly which may present as chronic abdominal pain . 
 abdominal ct is helpful for diagnosis . 
Introduction
Case Report
Discussion