In a 6‑year‑old girl with recurrent abdominal pain and vomiting every two months and imaging showing mild proximal small‑bowel dilatation with an abnormal duodeno‑jejunal junction consistent with incomplete intestinal rotation/malrotation, what is the recommended management?

Management of Intestinal Malrotation in a 6-Year-Old with Recurrent Symptoms

This child requires surgical consultation for a Ladd's procedure, as the imaging findings of incomplete intestinal rotation (malrotation) with an abnormally positioned duodenojejunal junction explain her recurrent symptoms and carry a risk of life-threatening midgut volvulus. 1, 2

Why Surgery is Indicated

Malrotation is a surgical diagnosis that warrants operative correction even in older children with chronic symptoms, because the risk of acute midgut volvulus—which can cause intestinal ischemia, infarction, and death—persists regardless of symptom chronicity. 1, 3, 2

• The upper GI study demonstrates the hallmark finding: the duodenojejunal junction is positioned on the right side rather than crossing the midline to the left of the spine at the level of the pylorus 1, 2
• While the CT shows the cecum in normal position and normal SMA/SMV relationship, this does not exclude malrotation, as up to 15% of individuals may have a normal mobile cecum despite malrotation 1
• The recurrent pattern of abdominal pain and vomiting every 2 months is consistent with intermittent partial volvulus or intermittent obstruction from Ladd's bands 4, 2

Clinical Context Supporting Surgical Intervention

In children over 1 year presenting with malrotation, vomiting (68%) and abdominal pain (57%) are the most common symptoms, and 58% report complete symptom resolution after Ladd's procedure. 2

• This child's episodic symptoms fit the classic pattern of chronic malrotation in older children, where intermittent obstruction from peritoneal bands (Ladd's bands) or intermittent volvulus causes recurrent pain and vomiting 4, 2
• The 2-month interval between episodes suggests intermittent mechanical obstruction rather than functional disease 4
• Upper GI series has 96% sensitivity for malrotation, though false negatives can occur with redundant duodenum or bowel distension 1

The Ladd's Procedure

Surgical correction consists of dividing Ladd's bands, reducing any volvulus, widening the mesenteric base, positioning the small bowel on the right and colon on the left, and performing appendectomy. 4, 2

• Laparoscopic approach is acceptable and results in discharge by postoperative days 1-3 in most cases 4
• At surgery, 60% of older children have malrotated orientation and 33% have non-rotated orientation; 22% have obstruction and 12% have active volvulus 2
• Even without acute volvulus at the time of surgery, the anatomic abnormality predisposes to future catastrophic volvulus 3, 2

Critical Pitfalls to Avoid

Do not dismiss this as functional abdominal pain or irritable bowel syndrome simply because symptoms are chronic and intermittent—malrotation can present with recurrent symptoms for years before acute decompensation. 5, 2, 6

• A previous case report describes a 17-year-old with five similar episodes over 2 months who was misdiagnosed with irritable bowel syndrome before emergent surgery revealed serious pathology 5
• Normal abdominal examination between episodes does not exclude malrotation 2, 6
• The fact that the CT was performed with oral contrast and bowel motion does not invalidate the upper GI findings—the upper GI series remains the gold standard for diagnosing malrotation 1, 2

Do not wait for bilious vomiting or acute presentation—while bilious vomiting indicates surgical emergency, non-bilious recurrent vomiting with documented malrotation also warrants surgical correction. 1, 3, 2