Intestinal malrotation with midgut volvulus and duodenal stenosis in a neonate: a case report

Intestinal malrotation and congenital duodenal stenosis are uncommon causes of intestinal obstruction in newborns. Their simultaneous occurrence is extremely rare and poses a diagnostic and therapeutic challenge. A 17-day-old full-term male neonate presented with persistent bilious vomiting, feeding intolerance, and poor weight gain since birth. He exhibited jaundice, edema, and abdominal distension, along with direct hyperbilirubinemia. An abdominal ultrasound revealed a whirlpool sign and abnormal positioning of the superior mesenteric artery and vein, indicating intestinal malrotation complicated by midgut volvulus. An exploratory laparotomy was performed, which revealed incomplete rotation and a mobile cecum, with Ladd’s bands obstructing the duodenum and a 360° clockwise volvulus. After detorsing the volvulus and performing a Ladd’s procedure, the baby showed initial improvement. However, ongoing bilious output from the nasogastric tube raised concerns about proximal obstruction. An abdominal X-ray done 72 hours later confirmed duodenal stenosis. A Heineke-Mikulicz duodenoplasty was subsequently performed, along with the insertion of a trans-anastomotic feeding tube and a decompression nasogastric tube. The neonate gradually advanced to full feeds, with the nasogastric tube being removed on postoperative day seven and the feeding tube on day ten. The neonate was discharged on the fourteenth postoperative day. Follow-up appointments two weeks, three months and six months post discharge indicated that the baby is thriving well. Duodenal stenosis should be suspected in neonates who have persistent bilious nasogastric output after a Ladd's procedure.