some other causes can be due to postoperative adhesions , duplication cyst , meconium  ileus  , and internal hernia . according to our knowledge , this is the first report of intrauterine volvulus of terminal ileum without malrotation that was diagnosed by ultrasound . our case deals with terminal ileum torsion around its axis with twisting of mesenteric vessels . therefore , it is of medical importance to recognize the radiological signs of bowel torsion as soon as possible . we present a case of volvulus of terminal ileum which was diagnosed and treated surgically in a neonate just 15 h after delivery . a female baby was born preterm at 35-weeks , with parameters appropriate for her gestational age , weighing 2666 g , with apgar 9 - 10 at 1 and 10 min , respectively . maternal history provided a previous missed abortion , otherwise the mother was a healthy woman who had a normal pregnancy and normal fetal screening follow - up findings . on physical examination of the preterm baby investigational work - up was started including , chest x - ray which was normal , arterial blood gases showed mild metabolic acidosis , blood and urine culture were obtained , and wide spectrum intravenous antibiotics were started . the baby was referred to our radiological department for plain abdominal x - ray at age of 2 h. the x - ray showed a distended and gasless abdomen , except for a small amount of air in the stomach [ figure 1 ] . female baby at 2 h after birth with distended abdomen diagnosed with intrauterine volvulus of terminal ileum without malrotation . x - ray of abdomen shows distended and gasless abdomen except a small amount of air in the stomach ( black arrow ) . this radiological finding might be normal at this age , but since the baby was crying it was assumed to have more air in the intestine . thus , we started an upper gastrointestinal study to rule out any cause of intestinal obstruction . the barium study ruled out a malrotation showing a normal gastric , duodenal , and normal location of the treitz ligament [ figure 2 ] . two hours after the start of the barium study , we noticed lack of propagation of the barium at the level of right lower quadrant of the abdomen . this led us to suspect ileal atresia , which is the most common cause of obstruction after malrotation . sign with filling defect and a round structure around this end loop [ figure 3 ] . this radiological finding suggested ileal obstruction due to volvulus with presumed duplication cyst as the leading point . female baby at 2 h after birth with distended abdomen diagnosed with intrauterine volvulus of terminal ileum without malrotation . female baby at 13 h after birth with distended abdomen diagnosed with intrauterine volvulus of terminal ileum without malrotation . at 13 h , the barium study shows stopage of barium with a beak - like shape of the pre - obstructed bowel ( black arrow ) with filling defect(white arrow ) and a structure containing air around the end loop ( arrowheads ) immediate ultrasonographic examination of the abdomen was done to confirm the diagnosis . ultrasound scan showed a target lesion consistent of two loops of bowel , pneumatosis of the bowel wall , and twisting of vessels [ figure 4 ] , suggesting a diagnosis of ileal volvulus with intestinal ischemia . intraoperative findings showed volvulus of terminal ileum with intestinal ischemia and perforation with free meconium in the abdomen . we think that meconium in this case was the main predisposing factor for the volvulus of this baby . female baby at 13 h after birth with distended abdomen diagnosed with intrauterine volvulus of terminal ileum without malrotation . ultrasonographic examination of the abdomen shows a target lesion consistent with two loops of bowel , pneumatosis of the bowel wall ( arrowheads ) and twisting of vessels ( white arrow ) . according to our knowledge , this is the first case of intrauterine volvulus of terminal ileum without malrotation , that was diagnosed definitively by ultrasound and operated on within a few hours after birth thus saving the life of the baby . neonatal volvulus is secondary to malrotation , and involves twisting of bowel loop with its feeding vessels that leads to ischemia , necrosis , and perforation with fatal complication , if not recognized and treated in time . however , other rare predisposing causes are meckel 's diverticulum , duplication cyst , and meconium plug . diagnosis of volvulus in any suspected neonatal intestinal obstruction by plain film and barium study is extremely difficult especially when malrotation is ruled out . the most common causes of these cases of intestinal obstruction are intestinal atresia that is fatal in the first hours of life if not treated immediately . based on our case , we suggest : in any case of suspected intestinal obstruction , first we have to rule out intestinal malrotation with an upper gastrointestinal barium study . once malrotation is ruled out , we suggest immediately performing an ultrasound examination of the abdomen to rule out an ileal volvulus . thus , ultrasound examination that shows a target lesion  bird beak  sign of the involved bowel allows to quickly identify this morbid entity without loss of precious time .
neonatal terminal ileum volvulus in the absence of malrotation has never been reported before in english literature . however , 
 another similar rare entity known as neonatal primary segmental volvulus without malrotation has been reported before . 
 volvulus , in general , is an extreme emergency and cases not diagnosed in time lead to death . 
 the main diagnosis is based on radiological features seen on imaging . 
 we present a case of volvulus of terminal ileum that was diagnosed and surgically treated at age of 15 h ensuring the newborn survived . 
 the definitive diagnosis was based mainly on ultrasonographic findings .