PMC4941200_01
Abdominal X-ray demonstrates dilated loops of small bowel. A paucity of colonic gas is noted on the right side with a predominance of small bowel in right upper quadrant.
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Upon further interrogation of the CT scan it was noted that the majority of bowel was on the right side of the abdomen (Fig. 1).
Abdominal Computed Tomography (CT). Abdominal CT shows thickened loops of bowel in the midabdomen with a prominent fecolith (white arrow). The right colon is absent from its normal anatomic position.
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Additionally, the right colon was noted to be in the midepigastrum, the duodenum do not cross the midline, and a fecolith in the bowel (Fig. 2a and b).
Intraoperative pictures demonstrate a midabdominal appendix. The appendix was perforated with a large fecolith (white arrow). The proximal jejunum (black arrow) is seen coursing the patient's right side and not crossing midline along the normal anatomic course (3a). Ladd's bands (white dotted lines) are seen originated from the cecum and right colon (3b).
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It was clear the patient did, in fact, have malrotation with the cecum and appendix position being in the middle of the abdomen (Fig. 3a). While Ladd's bands were clearly seen this was not the source of obstruction precipitating the patient's hospitalization as they did not course over the duodenum (Fig. 3b).
Appendiceal perforation. The appendix (black arrow) was found to be gangrenous and perforated at its base.
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The cecum was again identified in the middle of the abdomen and was noted to have a gangrenous appendix with several perforations as well as a large fecalith (Fig. 4).