Internal hernias are rare causes of intestinal obstruction, accounting for less than 1% of abdominal hernias and 0.6–5.8% of small bowel obstruction cases. Paraduodenal hernias are the most common congenital internal hernias,while right paraduodenal hernia being less frequent and often associated with intestinal malrotation [1]. This anomaly results from abnormal embryologic rotation and fixation of the midgut, leading to entrapment of small bowel loops through the fossa of Waldeyer [2]. Although intestinal malrotation is typically diagnosed in infancy, presentation in adulthood is uncommon and often nonspecific, with symptoms such as intermittent abdominal pain, nausea, vomiting, or recurrent subacute obstruction [3]. Contrast-enhanced computed tomography is essential for diagnosis, typically showing clustered small bowel loops, abnormal mesenteric vessel orientation, and displacement of adjacent structures [4]. Early recognition is important to prevent complications such as strangulation and bowel ischemia. Surgical repair, either open or laparoscopic, is the definitive treatment [5].

We report a rare case of right paraduodenal hernia with intestinal malrotation in an elderly adult, highlighting its diagnostic and therapeutic challenges.

A 63-year-old male presented to the emergency department with complaints of sudden-onset severe diffuse abdominal pain for two days . The pain was colicky in nature and associated with progressive abdominal distension, multiple episodes of bilious vomiting, and obstipation. The patient also reported a similar episode of abdominal pain and distension 12 days prior, which had been managed conservatively.

On general examination, the patient appeared distressed due to pain. On Per abdominal examination a distended and globular abdomen with diffuse tenderness and generalized guarding. Bowel sounds were exaggerated.

Routine laboratory investigations were performed. Abdominal radiography demonstrated multiple air-fluid levels suggestive of small bowel obstruction. Ultrasonography of the abdomen and pelvis showed an overdistended stomach and multiple dilated small bowel loops filled with intraluminal contents without appreciable peristaltic activity. The average bowel loop diameter was approximately 30 mm, with the largest measuring 44 mm. The large bowel appeared collapsed.

Contrast-enhanced computed tomography of the abdomen and pelvis revealed fluid-filled dilated bowel loops with multiple air-fluid levels suggestive of subacute intestinal obstruction, along with minimal free fluid within the peritoneal cavity.

In view of worsening abdominal signs and imaging findings suggestive of obstruction, emergency exploratory laparotomy was undertaken.

Intraoperatively, approximately 80 cm of dusky and dilated proximal bowel loops were identified. A stricture was present approximately 10 cm distal to the duodenojejunal flexure. Ladd's bands, along with the appendix, were identified distally. Normal bowel loops were seen passing below the Ladd’s band and subsequently entering a right paraduodenal sac, resulting in a right paraduodenal hernia. The duodenojejunal flexure was abnormally located on the right side. Additional findings included adhesions between the small bowel, liver, and gallbladder. The bowel loops further passed through a transverse mesocolic defect, producing an internal hernia before terminating at the ileocecal junction in the right iliac fossa.

The herniated bowel loops were reduced from the paraduodenal sac, following which the sac was transfixed and excised. Ladd’s bands were divided and excised. Appendicectomy was performed. The transverse mesocolic defect causing internal herniation was closed after reduction of the bowel loops. Following derotation of the gut, the cecum was positioned on the left side. The dusky bowel segment was resected, and jejunojejunal exteriorization with stoma creation on the right side was performed. A 32-Fr ROMO ADK drain was placed in the pelvis and secured to the skin. Abdominal closure was completed in layers.

The postoperative recovery was satisfactory, and the patient was discharged in stable condition with advice regarding regular follow-up.

Figure 1: Abdominal X-Ray showing multiple air-fluid levels

Figure 2: CECT of the abdomen and pelvis revealed fluid-filled dilated bowel loops with multiple air-fluid levels

Figure 3: Intra operative findings shows dusky & dilated bowel loops with stricture 10 cm from DJ flexure as proximal end and Ladd’s band containing appendix at distal end

Intestinal malrotation is a rare congenital anomaly in adults and may present with nonspecific symptoms such as recurrent abdominal pain, vomiting, or intermittent intestinal obstruction. Right paraduodenal hernia (RPDH), a congenital internal hernia associated with abnormal midgut rotation and entrapment of bowel loops within the fossa of Waldeyer. Delayed diagnosis can result in bowel strangulation and ischemia [6, 7].

The present case is unusual due to its occurrence in an elderly patient with associated intestinal malrotation, Ladd's bands, and RPDH causing acute intestinal obstruction with ischemic bowel changes. The patient had recurrent obstructive symptoms prior to definitive diagnosis, which is which has been commonly reported in adult cases of intestinal malrotation [8].

CECT of the abdomen is the investigation of choice and helps identify clustered dilated bowel loops, abnormal bowel orientation, and features of obstruction. However, preoperative diagnosis remains challenging because imaging findings are often nonspecific. In this case, emergency laparotomy confirmed RPDH with intestinal malrotation and compromised bowel viability [9, 10].

Surgical management remains definitive and includes reduction of herniated bowel, division of Ladd’s bands, closure of mesenteric defects, and resection of nonviable bowel when required. Early recognition and prompt intervention are essential to prevent strangulation, gangrene, and associated morbidity [11].

The present case is rare but unique due to the coexistence of right paraduodenal hernia, intestinal malrotation, transverse mesocolic internal hernia, and ischemic bowel in an elderly patient. A high index of clinical suspicion is necessary, particularly in elderly patients with recurrent obstructive symptoms without a history of prior abdominal surgery or evidence of abdominal tuberculosis. Early diagnosis and prompt surgical intervention are essential to prevent bowel ischemia, gangrene, and associated morbidity.

Patient Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying clinical details and images.

Conflict of Interest

The authors declare no conflict of interest.

Funding

No funding was received for this study.

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