Abstract
Introduction: Intestinal malrotation is a condition, which is predominantly recognised in childhood. Because of the relative rarity, there is a possibility that it can be missed in the routine clinical care of adults. This case highlights the need for a high index of suspicion for malrotation when things go wrong in routine procedures. This can be the reason for catastrophic sepsis in patients who undergo minimally invasive procedures.
Case presentation: We present a patient with a malignant lesion of the tongue who went for elective placement of feeding tube who suffered unexpected complication as a result of malrotated large bowel.
Conclusion: Malrotation of the intestine can make a relatively straightforward procedure fraught
with complications. Clinicians should have a high index of suspicion about malrotation when performing procedures like percutaneous gastrostomy and radiologically guided entrostomy. If there is an index of suspicion they should be screened prior to the procedure.