Anatomical Correction of Adult Intestinal Malrotation Using Kareem’s Procedure: A Case Report

Abstract

Background

Intestinal malrotation (IM) is a congenital defect in midgut rotation or fixation that results in abnormal positioning of the bowel. Although most cases present during infancy, adult presentation is uncommon and may be misdiagnosed. Kareem’s procedure is an anatomical corrective approach described for gut malrotation; however, evidence regarding its use remains limited.

Case Presentation

A 26-year-old female presented with sudden, severe, colicky central abdominal pain associated with non-bilious vomiting and complete constipation for 10 hours. She had experienced a similar self-limited episode one month earlier. Contrast-enhanced abdominal CT revealed inversion of the SMA/SMV relationship, right-sided clustering of small bowel loops, and abnormal position of the duodenojejunal junction, consistent with intestinal malrotation with acute complications. The patient underwent anatomical correction using Kareem’s procedure. At follow-up, she reported relief of abdominal pain, and CT confirmed normalization of the SMA/SMV relationship, cecal position in the right iliac fossa, and jejunal loops in the left abdomen.

Conclusion

IM should be considered in adults with unexplained abdominal pain or features of intestinal obstruction. Kareem’s procedure was feasible in this patient and was associated with a favourable outcome. Further evidence is needed before drawing conclusions about comparative effectiveness.

Introduction

During the embryonic period, the midgut undergoes a 270° counterclockwise rotation around the axis of the superior mesenteric artery (SMA), resulting in the normal position of the ileocecal valve in the right lower abdomen and the duodenojejunal junction on the left. This normal rotation and fixation produce a broad mesenteric base, which, together with proper bowel and mesenteric fixation, reduces abnormal intestinal mobility and the risk of midgut volvulus.^1–3 Intestinal malrotation (IM) occurs when there is abnormal or incomplete intestinal rotation and/or fixation, which may lead to volvulus, intestinal ischemia, and bowel loss.⁴ IM has an estimated incidence ranging from 1:500 to 1:5000 live births. However, symptomatic cases are less frequent, occurring in approximately 1 in 6000 live births. In adults, the incidence of IM is approximately 0.2%, making it an uncommon diagnosis that requires a high index of suspicion.^5,6

In children, 80% of cases present in the first month and 90% present in the first year. However, approximately 83% of adults remain asymptomatic and are discovered incidentally during radiology or surgery for other reasons.^6–8 Symptomatic patients may present with recurrent vague abdominal pain, vomiting, chronic diarrhea, and bloating, which may be mistaken for irritable bowel syndrome, peptic ulcer disease, pancreatic disease, or psychiatric disorders.^9–11 Approximately 20% of adult patients present with acute symptoms resembling acute intestinal volvulus.¹² The treatment of IM is surgical, with Ladd’s procedure remaining the traditional standard approach. In 2021, Kareem Abu-Elmagd introduced gut malrotation correction surgery, also known as Kareem’s procedure, as an anatomical corrective approach intended to restore bowel anatomy; however, evidence regarding its comparative effectiveness remains limited.^13,14

Here we present an adult case of intestinal malrotation managed with Kareem’s procedure. This case highlights the feasibility of anatomical correction in a selected adult patient and emphasizes the need for cautious interpretation because evidence remains limited.

Case Presentation

A 26-year-old female patient presented to the outpatient department with sudden onset, acute, severe, central abdominal pain for 10 hours. The pain was colicky, non-radiating, and associated with multiple episodes of non-bilious vomiting and absolute constipation. There were no other gastrointestinal symptoms. The patient reported a history of a similar episode one month before her current presentation, which lasted for 4 hours and resolved spontaneously. She had no prior history of abdominal surgery, trauma, or a family history of congenital anomalies.

Physical examination revealed a patient with stable vital signs: temperature of 37.0°C, blood pressure of 110/70 mmHg, pulse of 84 bpm, and a respiratory rate of 22 cpm. Remarkably, the abdominal examination was unremarkable as the abdomen was soft, with no distension, tenderness, or palpable masses. All laboratory investigations were within normal limits. Notably, the serum lactate level was 1.1 mmol/L, indicating the absence of advanced bowel ischemia at the time of presentation.

An urgent contrast-enhanced computed tomography (CT) scan revealed inversion of the mesenteric vessels, with the superior mesenteric vein (SMV) located to the left of the superior mesenteric artery (SMA) (Figure 1A), and right-sided clustering of small bowel loops. The jejunal loops were not in their usual anatomical location, and the duodenojejunal (D-J) junction was displaced (Figure 1B).

Figure 1.

Preoperative contrast-enhanced ct images, transverse sections. (A) Inversion of the mesenteric vessels is noted, with the superior mesenteric vein (SMV) situated to the left of the superior mesenteric artery (SMA). The white arrow indicates the duodenojejunal (DJ) flexure, the red arrow indicates the SMA, and the blue arrow indicates the SMV. (B) Right-sided clustering of small bowel loops with displacement of the duodenojejunal (D-J) junction. The black arrow indicates the gastric body, the green arrow indicates the proximal antrum, the orange arrow indicates distal jejunal loops, and the yellow arrow indicates the proximal jejunum with its mesentery.

Given these findings, the patient underwent an emergency laparotomy. Intraoperatively, intestinal malrotation with mesenteric vessel twisting was confirmed (Figure 2A and B). To achieve definitive anatomical correction and prevent recurrence, Kareem’s procedure was performed. The procedure involved complete mobilization of the duodenum and colon, followed by rotating the duodenum 180 degrees counterclockwise to a retro-mesenteric position. The colon was then rotated to position the cecum in its correct anatomical site within the right iliac fossa (RIF). A formal duodenopexy (Figure 3) and creation of a neo-ligament of Treitz were performed to stabilize the new configuration. The mesentery was then fixed to the posterior abdominal wall along a broad axis base. The cecum was successfully restored to its normal anatomical position in RIF. Total operative time was 130 minutes with minimal blood loss.

Figure 2.

Intraoperative images. (A) Midgut bowel twisting is indicated by the white arrow. (B) Reversed SMA/SMV relationship is shown, with the yellow arrow indicating the superior mesenteric artery (SMA) and the white arrow indicating the superior mesenteric vein (SMV).

Figure 3.

Duodenopexy step during Kareem’s procedure, showing fixation of the mobilized duodenum to help stabilize the corrected anatomical configuration.

The postoperative course was uneventful: the patient regained bowel function on the third day and was discharged on the fifth day. At six-month follow-up, a repeat CT scan confirmed the normalization of the SMA and SMV relationship (Figure 4A), proper positioning of the jejunal loops in the left abdomen (Figure 4B), and stable fixation of the cecum in the RIF (Figure 4C). The patient remains completely asymptomatic, with a full return to normal diet and daily activities.

Figure 4.

Postoperative ct images, transverse sections, at six-month follow-up. (A) Normalization of the SMA/SMV anatomical relationship following Kareem’s procedure. (B) Jejunal loops are shown in their usual anatomical location. (C) The cecum is shown in the right iliac fossa (RIF).

A comprehensive timeline of the clinical course, from recurrent symptoms to successful one-year follow-up, is illustrated in Figure 5.

Figure 5.

Comprehensive timeline of the patient’s clinical course, illustrating progression from recurrent gastrointestinal symptoms to acute presentation, diagnosis of intestinal malrotation with midgut volvulus, surgical correction using Kareem’s procedure, postoperative recovery, and successful one-year follow-up.

Discussion

IM is a rare congenital anomaly that occurs due to incomplete or abnormal rotation and/or fixation of the midgut around the SMA during embryonic development. Contrary to the common perception of its rarity, IM is not as rare as previously thought, with a reported incidence ranging from 1:500 to 1:5000 live births, with most cases occurring in infants or early childhood.^5,15 However, it remains an underrecognized cause of abdominal pathology in adults, accounting for only 0.2% to 0.5% of all cases.¹⁶ This discrepancy suggests that a significant portion of the adult population remains asymptomatic or, as seen in our case, is misdiagnosed with more common functional gastrointestinal disorders like IBS.

Embryologically, intestinal malrotation results from disruption of normal midgut rotation and fixation around the SMA. These abnormalities may leave the bowel and mesentery abnormally mobile, creating a narrow mesenteric base and increasing the risk of volvulus or obstruction. In adults, the clinical importance of this developmental abnormality lies less in embryological detail and more in recognizing its presentation and selecting an appropriate operative strategy.

The classic symptoms of IM in neonates or infants include bilious vomiting, failure to thrive, or intestinal obstruction. In adults, IM may present as chronic abdominal pain, especially postprandial discomfort, intermittent bowel obstruction, or nonspecific gastrointestinal symptoms, which can complicate diagnosis.^17–24 Most cases in adults are asymptomatic and identified incidentally during unrelated surgery or imaging.^16,25 While UGI series remains a classical diagnostic tool, particularly in pediatric patients, contrast-enhanced CT is generally more appropriate in adults because it provides detailed anatomical assessment of bowel position, mesenteric vessels, and associated complications.^{19,20,26–28}

The treatment for intestinal malrotation is primarily surgical, with Ladd’s procedure being the traditional standard surgical approach since its introduction in 1936 by Dr. William Ladd.^{12,17,26,29,30} Its key steps include untwisting the bowel if volvulus is present, dividing fibrous bands compressing the duodenum, widening the mesenteric base, repositioning the intestinal loops, and performing prophylactic appendectomy to avoid future diagnostic confusion related to abnormal appendix location.^{17,25–27,29–32} Ladd’s bands are abnormal congenital peritoneal fibrous bands that may extend from the malpositioned cecum or right colon across the duodenum to the right lateral abdominal wall. These bands can compress the duodenum and contribute to partial or complete duodenal obstruction, which explains the rationale for their division during surgical management. However, despite its effectiveness, Ladd’s procedure has notable limitations, including a re-volvulus rate of 1% to 51% and significant postoperative complications like infections and obstructions.¹⁴ Laparoscopic Ladd’s procedure may reduce surgical invasiveness in selected adult patients and has been associated with shorter hospital stay and favourable symptom improvement in reported adult series, although conversion, postoperative obstruction, persistent symptoms, or recurrent volvulus may still occur.^31,33,34

To address the anatomical limitations of non-anatomical correction, Kareem Abu-Elmagd introduced gut malrotation correction surgery, also known as Kareem’s procedure, in 2021.¹³ This anatomical corrective approach aims to restore bowel position and mesenteric orientation more closely to normal anatomy. The procedure includes mobilization of the duodenum and colon, division of Ladd’s bands when present, rotation of the duodenum to a retro-mesenteric position, repositioning of the cecum to the right iliac fossa, duodenopexy, creation of a neo-ligament of Treitz, and fixation of the mesentery to broaden and stabilize the corrected configuration.^13,14 Laparoscopic anatomical correction using Kareem’s procedure has also been reported as a minimally invasive adaptation for symptomatic gut malrotation, but current evidence remains very limited; therefore, it should be considered only in carefully selected patients where surgical expertise, anatomy, and clinical stability allow.³⁵

The available literature suggests that anatomical correction may offer a theoretical advantage by restoring bowel orientation and broadening mesenteric fixation; however, current evidence is limited and does not establish superiority over Ladd’s procedure. In Abu-Elmagd et al’s series, Kareem’s procedure was associated with favourable reported outcomes, but these findings require cautious interpretation and further validation in larger cohorts, adult-specific series, and studies with longer follow-up.^13,14 Therefore, the present case should be viewed as an additional adult experience rather than evidence of a new standard of care.

In the presented case, Kareem’s procedure was feasible in an adult patient with intestinal malrotation and was associated with symptom resolution and favourable postoperative imaging findings. This case highlights the importance of considering intestinal malrotation as a differential diagnosis in adults with acute or recurrent unexplained gastrointestinal symptoms and illustrates the potential role of anatomical correction in carefully selected patients.

The limitations of this report include its single-case design, six-month radiological follow-up, one-year clinical follow-up, and lack of a comparator group. This case cannot establish long-term safety, recurrence risk, or comparative effectiveness of Kareem’s procedure.

Conclusion

Intestinal malrotation in adults is an uncommon but clinically important condition that should be considered in patients with unexplained recurrent abdominal pain or features of intestinal obstruction. Contrast-enhanced CT is particularly useful in adult evaluation because it can define bowel position, mesenteric vessel orientation, and associated complications. In this adult patient, Kareem’s procedure was feasible and was associated with a favourable short-term outcome. However, because this report describes a single case with limited follow-up and no comparator group, further studies with larger cohorts and longer follow-up are required before conclusions can be drawn regarding long-term safety, recurrence risk, and comparative effectiveness.

Funding Statement

No funding was received for this study.

Data Sharing Statement

All data generated or analyzed during this study are included in this published article.

Ethics Approval and Consent to Participate

Ethical statement is not applicable.

Consent for Publication

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work. Individual contributions are as follows: Waheeb Radman Al-Kubati contributed to the conception and design of the case report, performed the surgical procedure, supervised the work, interpreted the clinical findings, and critically revised the manuscript. Mansour Mohammed Al-Hameli contributed to the radiological assessment, interpretation of imaging findings, and critical review of the manuscript. Nardeen Alqousi contributed to clinical data collection, literature review, drafting of the manuscript, and revision of the article. Anas Al-Kubati and Abdullah Al-Kubati contributed to data acquisition, literature review, manuscript drafting, and revision. Bilal Sleiay contributed to the literature review, manuscript drafting, and critical revision. Reporting Standard: The case report has been reported in line with the SCARE 2023 Criteria.³⁶

Disclosure

The authors declare that they have no competing interests.