Hiatal hernias occur when intra-abdominal contents protrude into the diaphragmatic opening. Of the four classifications, Type 4 hiatal hernias are the most rare and severe. They develop from herniation of the gastroesophageal junction and abdominal viscera other than the stomach into the thoracic cavity. The resulting increase in intrathoracic pressure can cause a wide variety of symptoms on presentation and potentially lead to misdiagnosis. We present a rare case in which a 78-year-old woman presented with nonspecific symptoms and was diagnosed with incarcerated Type 4 hiatal hernia with sigmoid volvulus. We also report a literature review from 2015 to emphasize the importance of recognizing diverse symptomatic presentations in complex Type 4 hiatal hernias and the need for a comprehensive evaluation, as early detection and prompt intervention are essential in preventing life-threatening complications.

Meckel\'s diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract with a 1-3% prevalence in the general population. The surgical management of symptomatic MD is well described in the literature, but there is still no consensus on the indication for prophylactic resection of incidental asymptomatic MD. To address this issue, we extensively reviewed the current literature and report our experience with laparoscopic management of an unusual case of MD causing ileal volvulus and acute peritonitis two weeks after a laparoscopic appendectomy for acute gangrenous appendicitis performed in another hospital. A 50-year-old man presented to the emergency department with acute and severe abdominal pain, vomiting, and constipation. He had undergone a laparoscopic appendectomy for acute appendicitis two weeks before in another hospital. The patient was apyretic, distressed, and seeking an antalgic position. The abdomen was mildly distended and tender, and the Blumberg sign was mildly positive in the central quadrants. The clinical picture deteriorated with fever, peritonismus, and leukocytosis. A CT scan showed an ileo-ileal adhesion near the ileocolic junction and dilatation of the upstream loops with the air-fluid levels. Through an urgent laparoscopy, a necrotic mass, the MD, was wedge-resected, and the surrounding ileal volvulus derotated. The postoperative course was uneventful. There is no definitive consensus on the appropriate management of incidental asymptomatic MD, although several studies have attempted to identify guiding criteria. Features of the MD, the patient\'s risk factors, clinical presentation, and surgical approach need to be considered to establish definitive guidelines for the management of incidental asymptomatic MD. In the absence of definitive guidelines, personal expertise and judgement are the main resources for the surgeon approaching an incidental asymptomatic MD.

UNASSIGNED: Intestinal malrotation is a congenital anomaly resulting from abnormal or incomplete rotation and fixation of the midgut during embryogenesis. It commonly presents in the neonatal period (75%) with sudden onset bilious vomiting and rarely beyond infancy (<10%).
UNASSIGNED: The aim of the study was to highlight the clinical features, radiological findings, and treatment outcomes of patients with malrotation presenting beyond infancy.
UNASSIGNED: Eleven consecutive cases of delayed presentation of malrotation presented over a period of 5 years (2017-2021). Data were analyzed retrospectively.
UNASSIGNED: Out of the 11 patients, four were female and seven were male. The age of patients ranged from 14 months to 18 years. Patients beyond infancy present usually with diffuse pain abdomen compared to neonates which present with sudden onset bilious vomiting and therefore difficult to diagnose. Five patients had associated abnormalities such as intussusception or nutcracker syndrome or mesenteric cyst or jejunal stricture or mesenteric lymphadenopathy along with malrotation. Patients underwent ultrasonography, upper gastrointestinal contrast study, and contrast-enhanced computed tomography abdomen to confirm the diagnosis. All patients underwent the Ladd procedure with four requiring resection anastomosis and one requiring excision of the mesenteric cyst. Eight out of eleven patients had favorable outcomes, two develop adhesive intestinal obstruction and required re-exploration, and one had persistent complaints of hematochezia.
UNASSIGNED: Malrotation beyond infancy is a rare diagnosis. Malrotation in older children is usually not suspected because of the wide range of symptoms. A high index of suspicion on ultrasound or computed tomography is required to demonstrate the reversal of superior mesenteric artery and superior mesenteric vein position and related conditions. Early intervention and treatment can prevent catastrophic events such as intestinal volvulus and intestinal ischemia in these patients.

BACKGROUND: A large jejunal diverticulum has been reported as a possible cause of volvulus and acute mesenteric ischemia (AMI) in adults. A large diverticulum of the small bowel complicated with volvulus has been reported before in literature. However, imaging findings of a large diverticulum of the small bowel complicated with both volvulus and AMI on MDCT are rarely described and reported. In this study, we reported a case with a large diverticulum, volvulus, and AMI concurrently; these three imaging findings were reviewed and described on MDCT, and the relevant literature was briefly introduced.
METHODS: We reported the case of a 69-year-old man who presented to our hospital with acute abdominal pain and vomiting. An emergent abdominal enhanced MDCT imaging was performed and demonstrated the volvulus secondary to a large diverticulum of the jejunum complicated with AMI. Here, a case was presented that highlighted unique imaging findings on MDCT, as well as a literature review.
CONCLUSIONS: A review of the literature revealed that a single jejunal diverticulum causing both volvulus and AMI is rare in adults. To our knowledge, a systemic description of their signs on MDCT in a case has not been reported yet.

A 36-year-old female at 36 weeks\' gestation presented with right upper quadrant abdominal pain. She had no prior surgeries. Her pregnancy had been uncomplicated up until her presentation. Abdominal ultrasound was negative for cholecystitis or cholelithiasis, and the appendix was not visualized. During the second day of her hospital course, an abdominal magnetic resonance imaging (MRI) was performed revealing dilated small intestine with air-fluid levels and an inverted-appearing, prominent cecum. She was urgently taken to the operating room for cesarean section followed by abdominal exploration. After delivery of the child, a cecal bascule was found, with a severely distended cecum. To our knowledge, this is the first report of a cecal bascule diagnosed by MRI, and the first diagnosis of cecal bascule in a pregnant patient requiring surgical intervention. We discuss the pathophysiology, diagnosis and treatment of cecal bascule and review the current literature of reported cases.

UNASSIGNED: Nowadays the majority of appendectomies are undertaken laparoscopically. The associated per and postoperative complications are well established and known. However, some rare postoperative complications continue to be reported such as small bowel volvulus.
METHODS: We report the case of 44-year-old women who developed a small bowel obstruction from acute small bowel volvulus due to early postoperative flanges five days after a laparoscopic appendectomy.
UNASSIGNED: Laparoscopy is associated with less adherences and morbidity however we must be careful in post operative course. Mechanical obstruction can happen even with laparoscopy procedure.
CONCLUSIONS: Occlusion earlier after surgery even with laparoscopy procedure must be explored. Volvulus can be incriminated.

BACKGROUND: Patients with intestinal malrotation with volvulus (MWV) may suffer bowel ischemia, which can be correlated with the timing of surgical intervention. The purpose of this study was to identify and assess time-blocks in the care of patients from initial physician assessment (IPA) to surgical intervention to highlight potential opportunities for improvement.
METHODS: Retrospective chart review of patients with MWV presenting to McMaster Children\'s Hospital between January 1st, 2000 and December 31st, 2020 (n = 31). Demographic data and time-blocks of care were identified and analyzed (p < 0.05 considered significant). All times were reported as medians.
RESULTS: 22 males (71%) and 9 females (29%) were identified; median age was 9.8 d. IPA to incision was 10.7hrs and surgical consult to incision was 3.4hrs. Time to incision for patients <1 y was not significantly different than those >1 y (10.5hrs vs 10.7hrs, p = 0.737). The use of ultrasound did not significantly affect time to incision (7.9hrs vs 12.0hrs, p = 0.128). For patients requiring resection or having pan-necrosis there was no significant difference in time from IPA (10.9hrs vs 10.5hrs, p = 0.238) or surgical consult to incision (4.0hrs vs 3.3hrs, p = 0.808).
CONCLUSIONS: Time from IPA to surgical consult and time from surgical consult to surgical intervention represented the largest proportions of time. Age, use of ultrasound, and need for resection or having pan-necrosis did not significantly affect the time to incision. This data may be used to inform opportunities for expediting the management of patients with MWV once they have presented to a physician.
METHODS: III.

Caecal volvulus is an uncommon surgical condition affecting mostly females in their second and third decade of life. It is of vital importance that the general surgeon recognises, resuscitates, diagnoses, and effectively treats these cases in a timely manner to maximise the chance of a positive outcome for the patient. Whilst there are several types of caecal volvulus, the treatment involves, in most cases, surgical intervention. There is a wide variety of surgical interventions that can be performed, ranging from caecopexy or fixation to lateral wall to performing a right hemicolectomy with primary ileocolic anastomosis. There are several factors that influence this decision and can also be based on an individual surgeon\'s expertise and experience. We present a case of a 21-year-old female who presented to our Emergency Department with lower abdominal pain, nausea, and vomiting. She was diagnosed with caecal volvulus with the aid of CT imaging, following which she underwent laparotomy in which caecal volvulus was noted. She underwent appendicectomy and caecopexy and was discharged after an uneventful recovery on post-operative day five and remains well on follow-up.

UNASSIGNED: Midgut malrotation is a congenital condition caused by insufficient normal intestinal rotation following physiologic gut herniation. Reverse rotation of the midgut is the rarest kind of intestinal malrotation, accounting for about 2%-4% of all cases.
UNASSIGNED: We report a case of a 26-year-old South Asian gravida with a previous history of quadruple miscarriage and ovulation induction, presented as intestinal obstruction due to reverse malrotation. An MRI of the abdomen indicated that the mesentery had become twisted around the SMA, resulting in a \"whirlpool\" pattern. Open exploration was done to accomplish lysis of restricting bands with appendectomy.
UNASSIGNED: Intestinal obstruction in pregnancy is uncommon, but when unrecognized in a timely fashion, it is associated with significant maternal and fetal mortality. A simple release of constricting bands without antimesenteric transposition seems to be the safest option in this situation.

UNASSIGNED: and Importance: Williams Syndrome (WS) is a well-recognized genetic disorder characterized by multi-system clinical manifestations. However, there are very rare gastrointestinal complications associated with patients with Williams Syndrome. We report the first transverse colon volvulus (TCV) case in an adult with pre-diagnosed Williams Syndrome.
UNASSIGNED: We report a case of a 22-year-old South Asian adult who presented with complaints of generalized progressive abdominal pain, distension, bilious vomiting, and constipation. Detailed history, physical examination, and radiological investigations confirmed the diagnosis of transverse colon volvulus. A subtotal colectomy with end-to-end anastomosis was done.
UNASSIGNED: Patients with Williams Syndrome can develop rare gastrointestinal complications like transverse colon volvulus due to congenital/physiological predisposing factors. It is a surgical emergency and should be diagnosed and managed optimally. In addition, physicians should keep TCV in differential diagnoses while dealing with patients of Williams Syndrome presenting with acute or subacute abdominal pain.