title: An unusual presentation of congenital intestinal malrotation in a nonagenarian.
abstract: BACKGROUND
  Appendicitis is a common surgical pathology with many clinical presentations. Diagnosis can be challenging if there is an alteration to the normal position of anatomical structures and their relationships.
  
  
  METHODS
  In this case, we report an unusual presentation of congenital intestinal malrotation in a nonagenarian presenting with generalized abdominal pain and lactic acidosis found to have perforated appendicitis. The patient was admitted to the Hospitalist service for abdominal pain and misdiagnosed with bowel obstruction secondary to previous "operation". After further review of imaging malrotation with internal hernia was suggested. The patient was taken emergently to the operating room and found to have perforated and gangrenous appendix in the midabdomen. An appendectomy was performed and patient was ultimately discharged home in good condition on postoperative day four.
  
  
  CONCLUSIONS
  Malrotation of the intestines is a developmental variant that occurs when normal fetal rotation of the intestines around the superior mesenteric artery and their peritoneal fixation fails to occur. Presentation typically occurs during infancy and diagnosis in an elderly patient is exceedingly rare. Operative intervention is often required as it is commonly associated with lactic acidosis or peritonitis.
  
  
  CONCLUSIONS
  Malrotation can go undiagnosed well into elderly life and can present with unusual signs and symptoms. CT is very helpful in aiding the diagnosis but itself can be misleading.
authors.affiliation: Houston Methodist Hospital, Department of Surgery, 6565 Fannin St., Houston, TX 77030, United States; Houston Methodist Research Institute, Department of Regenerative and Biomimetic Medicine, Surgical Advanced Technologies Lab, 6670 Bertner Ave., Houston, TX, 77030, United States. Electronic address: jsfernandez-moure@houstonmethodist.org.
authors.forename: Joseph S
authors.initials: JS
authors.lastname: Fernandez-Moure
authors.affiliation: University of Texas Health Science Center at Houston, 7000 Fannin St., Houston, TX, 77030, United States. Electronic address: Maya.L.Moses@uth.tmc.edu.
authors.forename: Maya L
authors.initials: ML
authors.lastname: Moses
authors.affiliation: University of Texas Health Science Center at Houston, 7000 Fannin St., Houston, TX, 77030, United States. Electronic address: Andres.Garcia@uth.tmc.edu.
authors.forename: Andres
authors.initials: A
authors.lastname: Garcia
authors.affiliation: Houston Methodist Hospital, Department of Surgery, 6565 Fannin St., Houston, TX 77030, United States. Electronic address: mmreader@houstonmethodst.org.
authors.forename: Michael M
authors.initials: MM
authors.lastname: Reader
keywords: Appendicitis; Elderly; Intestinal malrotation; Peritonitis