Christmas tree pattern ileal atresia with intestinal malrotation in a 15-day-old infant: A rare dual congenital anomaly in the pediatric population - A case report.

BACKGROUND: Intestinal atresia is a common cause of neonatal intestinal obstruction. Type IIIb, also known as "Christmas Tree" or "Apple Peel" atresia, is a rare and severe variant characterized by the absence of the mesentery and a distal small bowel coiled around a single arterial vessel. Its incidence is low, accounting for 5-10 % of small bowel atresias. Intestinal malrotation, occurs due to failure of normal embryological gut rotation, is also rare and can predispose to volvulus and duodenal obstruction. The coexistence of both anomalies is extremely uncommon.

CASE PRESENTATION: We report a 15-day-old-male neonate with progressive abdominal distension, bilious vomiting, and hyperkalemia. Abdominal radiographs showed features of small bowel obstruction, while ultrasound was inconclusive. Exploratory laparotomy revealed type IIIb ileal atresia with the classical "Christmas Tree" configuration and collapsed distal bowels. Additionally, incomplete intestinal rotation was identified with a free-floating cecum and right-sided duodenojejunal junction. Surgical resection of the distal collapsed ileum, cecum, and part of the ascending colon was performed, followed by creation of a double stoma (ileostomy and colostomy). The postoperative period was uneventful with good stoma function.

DISCUSSION: This case highlights the diagnostic and surgical challenges posed by a rare dual congenital anomaly. The Christmas Tree pattern increases the risk of short bowel syndrome, while malrotation adds potential for volvulus. Early operative intervention is essential, especially in resource-limited settings.

CONCLUSION: Clinicians must consider coexisting anomalies when evaluating neonatal intestinal obstruction. Prompt surgery and individualized management can lead to favorable outcomes even in complex cases.