Norwich paediatric triad: malrotation, intussusception and small intestinal lymphoma.

To cite: Sinha C K, Basson S, Patel R V, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/ bcr-2013-201110 DESCRIPTION A previously healthy 13-year-old girl presented with abdominal pain for 2 days, initially in the periumbilical area and subsequently in the left upper quadrant. She had a few episodes of green vomiting, but had normal bowel movements. On examination, she was alert and haemodynamically stable. Her abdomen was tender in the left upper quadrant and had a soft mass. Laboratory investigations and chest radiograph were normal except for microcytic anaemia. Abdominal radiograph showed abnormal distribution of dilated bowel loops (figure 1A) and ultrasound scan revealed a target and pseudo kidney signs suggestive of an intussusception with a possible lead point on the left side of her abdomen and raised concerns of malrotation (figure 1B). Abdominal CT scan with contrast revealed intussusception, a lead point and associated midgut malrotation (figure 1C, D). At laparotomy, a midgut malrotation with ileocolic intussusception and a fleshy mass as lead point were found with viable bowel. A limited right hemicolectomy using Ladd’s procedure was performed uneventfully. Histopathology confirmed the lead point to be non-Hodgkin’s lymphoma. The patient was started on an appropriate chemotherapy regime by the oncology team. A combination of malrotation and intussusception is called Waugh’s syndrome. Triad of midgut malrotation, ileocolic intussusception and gut lymphoma has not been reported earlier in the literature in children and only one case has been reported in adults. We have named it ‘Norwich triad’. Air enema reduction is difficult, and recurrence is inevitable due to lead point delaying the diagnosis and treatment. At exploration the lead point should be resected for detailed histopathological diagnosis.