From the Department of Pediatric Surgery, Christian Medical College and Hospital, Vellore 632 004, Tamil Nadu.
Reprint requests: Dr. Jacob Chacko, Senior Reader, Department of Pediatric Surgery, Christian Medical College and Hospital, Vellore 632 004, India.

Manuscript Received: July 19, 1999;
Initial review completed: July 29, 1999;
Revision Accepted: October 28, 1999

Colonic obstruction is a rare presentation of malrotation, which occurs in reverse rotation (type IIB). We report an 80-day-old infant who presented with a colonic obstruction but was found to have a classical malrotation with mid-gut volvulus on exploration.

An 80-day-old infant, born full-term and thriving well, presented with constipation and abdominal distension of three days duration. There was no history of vomiting or passage of blood per rectum. On examination, there was generalized abdominal distension with visible bowel loops. Plain X-ray of the abdomen was suggestive of a lower intestinal obstruction. With a provisional diagnosis of Hirschsprung’s disease, a barium enema was done. This showed an obstruction at the level of transverse colon with a beak like termination of the column of barium. With these findings, although rare, the possibility of a colonic stenosis was entertained and a laparotomy was done. At laparotomy, there was evidence of a classical malrotation with incomplete volvulus. The volvulus was untwisted in a counter clockwise direction and the obstruction was relieved. It was found that a knuckle of mid-transverse colon was caught in the twist of the mesentery and this was the site of obstruction. The duodenum itself was not obstructed, as in a classic malrotation and there was distension of the small bowel and the ascending colon upto the knuckle in the mid-transverse colon.

After untwisting the bowel, features of a classic malrotation were found. The C-loop of the duodenum was not formed and the duodenojejunal flexure was on the right side. Ladd’s bands were extending between the cecum and the duodenum. The entire bowel was healthy. Division of Ladd’s bands and separa-tion of the duodenum and the cecum was carried out along with an appendicectomy. The patient had a smooth post-operative recovery.

Classical malrotation of the bowel with small-bowel volvulus presents primarily as a duodenal obstruction. Colonic obstruction with malrotation has been described in reverse rotation (type IIb)(1). However in the case reported, a classic malrotation with volvulus presented with a colonic obstruction and therefore with misleading symptoms. Here, part of the colon was caught in the twist of the mesentery because of which the transverse colon itself got obstructed, and the mesentery twisted only partially because of the added bulk of the colon that was caught, as a result of which the duodenal obstruction could not occur. A colonic obstruction in a classic malrotation is a rare occurrence and we have not come across any such report in the literature. One should keep in mind, the possibility of a malrotation with volvulus with this clinical presentation and radiological finding.

1. Toloukian RJ, Smith EI. Disorders of rotation and fixation. In: Pediatric Surgery, 5th edn. Eds. O’Neill JA, Rowe MI, Grosfeld JL, Fonkalsrud EW, Coran AG. Missouri, Mosby-Year Book, Inc., 1998; pp 1199-1214.