While uncommonly found pathologically together in the adult patient, visceral herniation and gut rotation go hand-in-hand during embryologic development. Rapid growth of the small bowel around week 6 of gestation results in physiologic herniation of the gut through the umbilical ring; the small bowel then rotates a full 270 degrees in a counter-clockwise direction to arrive at its normal anatomic position within the peritoneal cavity. Defects and missteps in these processes can have broad

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... uences for patients of all ages, as seen in our patient here. A 40-year-old gentleman with a history of an epigastric hernia presented with two days of abdominal pain, discomfort, and a palpable lump in the anterior abdominal wall; his primary care doctor had promptly sent him to the Emergency Room after a brief office evaluation. The hernia had been reducible in months past, but the patient had not attempted reduction for several weeks. He denied any fevers, chills, nausea, vomiting, bowel changes or failure to move his bowels at that time. He also denied any previous surgeries. On physical examination, a tender, supra-umbilical hernia was noted with palpable loops of bowel present in hernia sac; the hernia was not-reducible even after abdominal relaxation and narcotics administration. No peritoneal signs were noted, and the abdomen was not distended. A CT scan obtained in the emergency room was consistent with colonic malrotation along the midline; the appendix and mesentery were also identified within the her-Abstract Background: A male patient with previously undiagnosed intestinal malrotation presented with symptomatic appendiceal incarceration within an epigastric hernia.