1085 Atypical Epigastric Typhoid Perforation Unmasking an Incidental Adult Midgut Malrotation: A Rare Clinical Co-existence

Abstract Background Typhoid fever–related ileal perforation remains a life-threatening abdominal emergency, particularly in low-resource settings where early diagnosis is challenging. Reported global incidence varies widely due to inconsistent diagnostic criteria and limited surveillance. Recognized risk factors include delayed or inappropriate antibiotic therapy and male gender. While typhoid fever is the most common cause of ileal perforation, congenital anomalies such as intestinal malrotation are extremely rare in adults and often remain asymptomatic. Incomplete malrotation, characterized by failure of normal 270° counterclockwise gut rotation, may alter anatomical positions—most notably a high-lying caecum—potentially modifying clinical presentation. Case Report A 33-year-old male presented with six days of high-grade fever, severe epigastric pain, and vomiting. Examination revealed peritonism, with pain disproportionately localized to the epigastrium and RUQ. Radiography demonstrated free air under diaphragm and multiple air-fluid levels. Following resuscitation, an emergency laparotomy was performed. Intraoperatively, 2 L of turbid fluid and an unexpected incomplete malrotation were identified, with the caecum and ileocecal junction located in the epigastrium—accounting for the atypical pain distribution. A 2 × 2 cm ileal perforation located 15 cm proximal to the ileocecal junction was treated with loop ileostomy due to edematous gut. Histopathology confirmed inflammatory changes consistent with typhoid ulceration, without granulomatous or malignant features. The patient recovered well and underwent successful ileostomy reversal at three months. Conclusions This case highlights an unusual presentation of typhoid ileal perforation influenced by underlying intestinal malrotation. Awareness of such anatomical variations is crucial, as they may obscure classical clinical patterns and delay timely surgical intervention.