An unusual presentation of congenital intestinal malrotation in a nonagenarian

• Congenital intestinal malrotation can go undiagnosed late in life and as late as into 90 years of age.
• CT imaging is necessary for diagnosed yet can be misleading in the presence of other ongoing pathologies.
• Lactic Acidosis and peritonitis in the setting of malrotation are a surgical emergency.
• Careful and thorough review with awareness of “classic” radiographic signs of malrotation are important for diagnosis.

IntroductionAppendicitis is a common surgical pathology with many clinical presentations. Diagnosis can be challenging if there is an alteration to the normal position of anatomical structures and their relationships.Case presentationIn this case, we report an unusual presentation of congenital intestinal malrotation in a nonagenarian presenting with generalized abdominal pain and lactic acidosis found to have perforated appendicitis. The patient was admitted to the Hospitalist service for abdominal pain and misdiagnosed with bowel obstruction secondary to previous “operation”. After further review of imaging malrotation with internal hernia was suggested. The patient was taken emergently to the operating room and found to have perforated and gangrenous appendix in the midabdomen. An appendectomy was performed and patient was ultimately discharged home in good condition on postoperative day four.DiscussionMalrotation of the intestines is a developmental variant that occurs when normal fetal rotation of the intestines around the superior mesenteric artery and their peritoneal fixation fails to occur. Presentation typically occurs during infancy and diagnosis in an elderly patient is exceedingly rare. Operative intervention is often required as it is commonly associated with lactic acidosis or peritonitis.ConclusionsMalrotation can go undiagnosed well into elderly life and can present with unusual signs and symptoms. CT is very helpful in aiding the diagnosis but itself can be misleading.