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The clue to the diagnosis in this case is the inverted orientation between the superior mesenteric artery (SMA) and the superior mesenteric vein (SMV). Due to the normal 270° counter clockwise rotation of the midgut during embryological development, the SMA is normally positioned left of the SMV. Here the ultrasound scan demonstrated the SMA to the right of the SMV. In addition, a dilated small bowel was present. These features are characteristic of an intestinal malrotation (non-rotation) of the midgut. Endoscopy followed by upper gastrointestinal contrast series revealed duodenal obstruction. A contrast enhanced computed tomography scan showed complete malrotation with an obstruction in the distal duodenum. This was confirmed at laparatomy and a gastrojejunostomy and resolving of adhesions were performed. A gastrointestinal contrast series four days postoperatively demonstrated correct contrast passage into the jejunum. After oral refeeding, the patient’s postprandial complaints were improved.

Intestinal malrotation occurs in approximately 1 in 1000 live births. Symptomatic malrotation is estimated to occur in 1/6000 live births, with an increased risk for volvulus, twisting, small bowel obstruction, or other anomalies. Approximately 90% of patients present within the first months of life. It has to be considered an uncommon diagnosis in adult patients presenting with signs and symptoms of acute or chronic small bowel obstruction.

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