Hrev_master [page 48] [Emergency Care Journal 2025; 21:13647] Emergency Care Journal 2025 volume 21:13647 Abstract Common mesentery is a rare congenital anomaly caused by abnormal rotation of the omphalomesenteric loop during embryon- ic development. We report the case of a 37-year-old woman who presented with lower abdominal pain and fever. Physical examina- tion revealed localized tenderness, and laboratory tests showed ele- vated inflammatory markers. Computed tomography revealed common mesentery with small bowel obstruction, and abnormal cecal positioning. There were no signs of ischemia or perforation. Conservative treatment was initiated, including nasogastric decompression, Gastrografin challenge, intravenous fluids, anal- gesics, and antiemetics. The patient improved clinically, tolerated refeeding, and was discharged on day five. At three-month follow- up, she remained asymptomatic. Magnetic resonance imaging con- firmed the congenital anomaly and excluded other pathological findings. This case demonstrates that non-operative management may be an effective option in stable adult patients with bowel obstruction due to common mesentery. Introduction The common mesentery is a rare congenital anomaly resulting from incomplete or abnormal rotation of the primitive intestinal loop (omphalomesenteric loop) during embryonic development. While it is not always symptomatic, it can occasionally present clinically as acute bowel obstruction caused by a fibrous band or volvulus.1,2 The condition is typically diagnosed with imaging studies such as Computed Tomography (CT) or Magnetic Resonance Imaging (MRI), revealing anatomical anomalies like abnormal positioning of the cecum or inversion of the mesenteric vessels.3 We present a case of a patient with common mesentery who was admitted for bowel obstruction and successfully managed with non-operative treatment. Case Report Patient information A 37-year-old woman presented to the emergency department with acute abdominal pain localized to the lower quadrants and fever. She reported progressive lower abdominal pain over the pre- vious 48 hours, described as cramping and intermittent. The pain was not related to food intake, bowel movements, or menstruation, and she denied any associated gynecological symptoms such as abnormal vaginal bleeding or discharge. She also denied nausea, vomiting, or urinary symptoms. Her medical history was unre- markable, and she had no prior abdominal surgeries. There was no family history of inflammatory bowel disease, gastrointestinal dis- orders, or congenital anomalies. Clinical findings On physical examination, the patient was afebrile, hemody- namically stable, and alert. Abdominal examination revealed dif- fuse tenderness in the lower quadrants without signs of peritonitis. Laboratory findings included: elevated C-Reactive Protein (CRP) (20.3 mg/L); normal White blood cell count (8.97 x 10³/μL), Hemoglobin (13.1 g/dL), Creatinine (0.75 mg/dL), and International Normalized Ratio (INR) (1.09). Other parameters, including liver and kidney function tests, were within normal lim- its. Additional laboratory tests were performed to exclude metabol- ic or gynecological causes. Lactate levels were within normal lim- its, as well as arterial blood pH. A urine dipstick was unremark- Correspondence: Manuela Mastronardi, Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy. E-mail: manuela.mastronardi@gmail.com Key words: bowel obstruction, common mesentery, non-operative management. Conflict of interest: the authors declare no conflict of interest. Ethics approval and consent to participate: no ethical committee approval was required for this case report by the Department, because this article does not contain any studies with human partic- ipants or animals. Informed consent was obtained from the patient included in this study. Patient consent for publication: the patient gave her written consent to use her personal data for the publication of this case report and any accompanying images. Availability of data and materials: all data underlying the findings are fully available. Received: 18 January 2025. Accepted: 12 May 2025. Early view: 4 July 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Emergency Care Journal 2025; 21:13647 doi:10.4081/ecj.2025.13647 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. Non-operative treatment for bowel obstruction in a 37-year-old woman with common mesentery: a case report Manuela Mastronardi,1 Biagio Casagranda,2 Nicolò de Manzini,1,2 Silvia Palmisano1,2 1Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste; 2Surgical Clinic Division, Cattinara Hospital, ASUGI, Trieste, Italy able, with no signs of infection or hematuria. Serum β-hCG test was negative, excluding pregnancy (Table 1). Diagnostic assessment Considering the negative serum β-hCG test, the patient had o contraindication to undergo a contrast-enhanced CT scan of the abdomen and pelvis as the first-line imaging modality. The CT showed incomplete common mesentery with the cecum positioned in the upper right quadrant. The superior mesenteric vein was located to the left of the artery, consistent with vascular inversion (Figure 1). Distension of small bowel loops suggested obstruction. No signs of ischemia, perforation, or thickened bowel walls were noted. Therapeutic intervention Upon admission, a nasogastric tube was placed for decompres- sion, intravenous fluids were administered, and a Gastrografin challenge was performed. Eight hours after Gastrografin adminis- tration, an abdominal X-ray was performed but the Gastrografin had not yet opacified all bowel loops. However, since the patient’s symptoms had improved, in the absence of concerning blood test results, a decision was made to continue with conservative man- agement. The following day, the patient passed stool, therefore, the nasogastric tube was removed, and oral feeding was gradually reintroduced as tolerated. Follow-up and outcomes The patient was discharged after 5 days. At three-month fol- low-up visit, she tolerated the diet well and reported no pain or gastrointestinal problems. She remains asymptomatic with no recurrence of bowel obstruction. A digestive tract MRI confirmed incomplete common mesentery. No significant bowel thickening or pathological findings were observed. Minimal free fluid in the pelvis was deemed physiological. The study also confirmed mesenteric vessel inversion and abnormal positioning of the duo- denum. Discussion This case highlights the rare presentation of bowel obstruction due to common mesentery in adulthood. The significance of this case lies in its rarity and the successful conservative management of a condition that typically requires surgical intervention.4 This congenital anomaly can occasionally result in bowel obstruction or volvulus, as observed in this case. While the condition is often asymptomatic and undiagnosed, its clinical manifestation in adulthood is exceedingly rare, with an estimated prevalence of 0.2% to 0.5%.1,5-7 The clinical presentation can be highly variable, ranging from incidental findings in asymp- tomatic individuals to acute surgical emergencies. While many individuals remain asymptomatic and the anomaly is discovered incidentally, others may present with acute or chronic abdominal symptoms. Possible presentations include intermittent abdominal pain, symptoms of partial or complete bowel obstruction, and, in more severe cases, volvulus with signs of peritonitis.8-12 This vari- ability is due to the altered anatomical configuration, which can lead to atypical positioning of the bowel and mesenteric vessels, complicating the clinical picture.13 The presence of associated anomalies, such as Ladd’s bands or Meckel’s diverticulum, can further obscure the diagnosis. For this reason, in patients with unexplained abdominal pain, especially when imaging reveals Article Table 1. Laboratory values at admission and at discharge. Parameter At admission At discharge Reference range White blood cells 8.97 x10³/μL 7.82 x10³/μL 4.0-11.0 x10³/μL Hemoglobin 13.1 g/dL 13.2 g/dL 12.0-16.0 g/dL C-Reactive Protein 20.3 mg/L 3.5 mg/L <5.0 mg/L Creatinine 0.75 mg/dL 0.70 mg/dL 0.5-1.0 mg/dL INR 1.09 1.02 0.8-1.2 Lactate 1.3 mmol/L - 0.5-2.2 mmol/L Arterial pH 7.4 - 7.35-7.45 Urine dipstick Negative - - β-hCG (serum) Negative - Negative (non-pregnant) Figure 1. Axial section of contrast-enhanced computed tomogra- phy (CT) scan of the abdomen. The image shows distended small bowel loops, suggestive of obstruction, and vascular inversion: the superior mesenteric vein (blue arrow) is located to the left of the superior mesenteric artery (red arrow), which is consistent with common mesentery. No signs of bowel ischemia, wall thickening, or perforation are visible. [Emergency Care Journal 2025; 21:13647] [page 49] abnormal bowel positioning or vascular inversion, congenital anomalies like common mesentery should be considered.14 Cross- sectional imaging plays a crucial role in identifying these condi- tions early and guiding appropriate management. The patient’s presentation of acute bowel obstruction without signs of ischemia or perforation posed a diagnostic and therapeutic challenge. Imaging studies played a crucial role in identifying the anomaly. Contrast-enhanced CT revealed hallmark features of common mesentery, such as abnormal cecal positioning and mesenteric vessel inversion. It also showed signs of small bowel obstruction, without evidence of ischemia. This aligns with the importance of CT as the gold standard for diagnosing intestinal malrotation and related complications.1,15-17 Conservative management was chosen based on the patient’s stable clinical condition, absence of alarming findings on imaging, and her progressive symptomatic improvement. Nasogastric decompression, intravenous fluid resuscitation, and a Gastrografin challenge were employed, allowing for symptom resolution with- out surgical intervention. This outcome underscores the potential of Non-Operative Management (NOM) in carefully selected cases, despite the rarity of such an approach in adult patients with com- mon mesentery. Most reported cases in adults have required surgi- cal correction, often involving the Ladd procedure to address volvulus and anatomical anomalies.1,3,15,18,19 The decision to pursue conservative management was support- ed by clinical improvement and the lack of laboratory or imaging evidence suggesting bowel ischemia. Symptom resolution and absence of recurrence at follow-up support the appropriateness of this approach. However, it is critical to note that conservative management should only be considered when there is no evidence of bowel compromise, as delayed treatment in cases of ischemia or total volvulus can lead to catastrophic outcomes. From an anatomical perspective, this case illustrates the char- acteristic features of incomplete common mesentery, including a shortened mesenteric root and mesenteric vessel inversion, which predispose patients to complications like volvulus. While surgical intervention remains the standard of care in most cases of small bowel volvulus associated with common mesentery,15,18,20 this case demonstrates that NOM can be a viable alternative in selected patients. This case emphasizes the importance of individualized patient management and highlights the potential for successful conserva- tive treatment in rare and complex conditions like incomplete com- mon mesentery with bowel obstruction. It also underscores the need for awareness of this anomaly and its possible complications, even in adults, to avoid delays in diagnosis and treatment. Further studies and case reports may help refine criteria for selecting patients who can benefit from NOM, potentially reducing the need for surgical intervention in similar scenarios. Conclusions Bowel obstruction due to common mesentery is a rare clinical entity in adults. This case underlines the critical role of cross-sec- tional imaging in both diagnosis and treatment planning, and high- lights how individualized, patient-centered management can suc- cessfully avoid surgical intervention in selected cases. Advanced imaging modalities such as CT and MRI are invaluable in diagnos- ing and guiding the management of this condition. A multidisci- plinary approach and patient-centered decision-making are essen- tial for optimal outcomes. Patient perspective The patient expressed relief and satisfaction with the conserva- tive approach, particularly the avoidance of surgery. She appreci- ated the clarity of communication regarding her condition and the collaborative decision-making process. References 1. Jabra SB, Chaouch MA, Moussa A, et al. Incomplete common mesentery with Ladd’s band and Meckel’s diverticulum: A rare cause of small bowel obstruction. Int J Surg Case Rep 2023;106:108159. 2. Oudou AZ, Soumana ID, Souiki T, et al. Volvulus total du grêle sur mésentère commun incomplet, une complication excep- tionnelle chez l’adulte: à propos d’un cas. Pan Afr Med J 2019 J;33:220). 3. Aissaoui R, Nasri S, Mahjouba H, et al. 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