A primary side-to-side jejeno-jejeunal anastomosis was fashioned. The small bowel was examined again, with no further haemorrhage noted. Figure 1 Contrast enhanced CT axial images at the level of L2 demonstrating abnormal rotation of the proximal jejunum (short check details arrows). Note the swirling of the superior mesenteric vein (long arrow). Figure 2 CT, coronal reformatted images

demonstrating abnormal rotation of the proximal jejununum, with proximal segment extending horizontally across the midline to the right side of the abdomen (arrows). Six units of blood were transfused during the operation. see more The patient was managed on the high dependency unit for 48 hours and was transferred to the surgical ward. His recovery was complicated by an infection of his central venous catheter site and Clostridium difficile-associated diarrhoea. He was discharged 14 days following surgery, with no evidence of further gastrointestinal bleeding or cardiovascular instability. Histological examination of the resected small bowel demonstrated focal dilatation of vessels within the mucosa, submucosa and muscularis propria layers, with areas of erosion, in keeping with the likely source of haemorrhage (Figure 3). There was no evidence of thrombosis, vasculitis or neoplasia. The patient remained well at three month follow-up with no further drop in haemoglobin or signs of gastrointestinal bleeding. Figure 3 Histological examination

demonstrates dilated blood vessels within the submucosa (arrows). Discussion

An association between congenital malrotation of the midgut and life-threatening gastrointestinal bleeding has not been previously reported find more in patients over 50 years of age. In patients aged above 50, angiodysplasia occurs with greater frequency and may present as intermittent Baricitinib gastrointestinal bleeding, most commonly with iron deficiency anaemia with normal upper and lower gastrointestinal endoscopy[4]. Haemodynamically stable patients are amenable to further investigation, which may include capsule endoscopy, CT angiography and percutaneous selective mesenteric angiography[3]. These investigations are time consuming and may not produce a positive diagnosis in the presence of low rates of blood loss less than 0.5 to 1 ml/min. Nuclear imaging studies with radiolabelled red cells are useful to identify the site of haemorrhage. This test is also time consuming and is not applicable to patients who are haemodynamically unstable. The discovery of malrotation at laparotomy was unexpected. Malrotation reportedly occurs in 1 in 500 live births, with over 80% presenting within the first month of life[5]. The true prevalence of malrotation in the adult population is unknown, although it is a finding on 1 in 500 gastrointestinal contrast studies[6]. The mesentery of the malrotated bowel is more tortuous, making the vascular supply more precarious. Patients typically present with signs of obstruction, intestinal ischaemia or haemorrhage[7].