II. Definitions
-
Volvulus
- Twisting of intestinal loop around attachment to mesentery
- Can occur at Stomach (Gastric Volvulus), Small Intestine, cecum, transverse colon or sigmoid colon
- Midgut Volvulus (Malrotation with Volvulus)
- Associated with Intestinal Malrotation
- Presents in infants in 90% of cases
III. Epidemiology
- Malrotation with Volvulus often presents in first few weeks of life (60% present in first year of life)
IV. Symptoms: Midgut Volvulus (infants and children)
- Infants
- Bilious Emesis
- Sudden onset of Abdominal Pain
- May present with Failure to Thrive and "reflux"
- Older children
- Chronic intermittent Vomiting and abdominal cramping
- Failure to Thrive
- Constipation
- Bloody Diarrhea
V. Signs
- Abdominal exam may be benign
- Abdominal Distention is often a late finding in acute Volvulus
-
Heme positive stool
- Late sign suggesting infarcted bowel
VI. Differential Diagnosis
- See Abdominal Pain Causes
VII. Imaging
- Acute Midgut Volvulus (children): Abdominal Xray
- Often non-specific
- Dilated Stomach and proximal duodenum with intervening pylorus (Double Bubble Sign)
- Double-Bubble is also seen in Duodenal Atresia (typically diagnosed in newborn nursery)
VIII. Complications
- Intestinal infarction (high mortality)
IX. Management
- Acute stabilization
- ABC Management
- Fluid Resuscitation
- Correct Electrolyte abnormalities
- Broad spectrum antibiotics for peritonitis
- Nasogastric Tube decompression
- Emergent surgical management
- Mesenteric Infarction and necrosis starts within first 3 hours of onset
- Necrotic bowel resected if needed
- Ladd Procedure reduces the Volvulus
- Bowel rotated counter-clockwise
- Mesenteric bands (Ladd Bands) are divided
- Small Bowel placed on the right side of Abdomen
- Large Bowel placed on the left side of Abdomen
- Appendectomy
- Widens mesenteric pedicle and reduces risk of Volvulus recurrence (but does not correct malrotation)
X. Resources
- Hebra (2012) Intestinal Volvulus, Medscape
XI. References
- Jones (2022) Crit Dec Emerg Med 36(2): 14-5
- Lampl (2012) Pediatr Radiol 39:359-66 [PubMed]
- Laurence (2012) Pediatr Emerg Care 28(1): 87-9 [PubMed]