Epigastric typhoid ileal perforation unmasking an incidental adult midgut malrotation: a rare clinical co-existence.

Peritonitis due to typhoid ileal perforation is a life-threatening surgical emergency that remains common in endemic regions but is rarely encountered in developed countries. Anatomically, its presentation is mostly localized to pain in right iliac fossa. A 33-year-old man presented with six days of fever, severe epigastric pain, vomiting, and septic shock. Because of the marked epigastric tenderness and pneumoperitoneum on X-rays, perforated peptic ulcer was the leading preoperative diagnosis. Emergency laparotomy instead revealed severe peritoneal contamination, incidental incomplete midgut malrotation with the caecum and ileocaecal junction in the epigastrium, and a 2 × 2 cm ileal perforation 15 cm proximal to the ileocaecal junction. A loop ileostomy was performed. Histology and blood cultures confirmed typhoid fever. The patient recovered uneventfully and underwent successful ileostomy reversal. This case highlights how intestinal malrotation can disguise the classical presentation of typhoid perforation, emphasizing the importance of diagnostic suspicion and intraoperative adaptability.