Volvulus

Snapshot

• A 2-day-old neonate presents with bilious vomiting and irritability. On physical examination, she has abdominal distention and high-pitched bowel sounds. Barium enema radiograph reveals a dilated sigmoid colon with a column of barium resembling a “coffee bean”.

Introduction

• Malrotation of gut from errors during development increases risk of volvulus
• Volvulus (typically, midgut) 
  • abnormal rotation of bowel
  • strangulation of SMA
  • compromised blood flow to bowel
• Epidemiology
  • most common in newborns
  • males > females
• Associated conditions
  • situs inversus
  • cardiovascular defects
  • heterotaxy
• gastroschisis/omphalocele

Presentation

• Symptoms
  • neonates
    • bilious vomiting within first week of life
    • colicky pain
  • older patients
    • bilious or nonbilious vomiting
    • crampy abdominal pain
    • change in bowel pattern
    • nausea
• Physical exam
  • abdominal distention
• abdominal tenderness

Evaluation

• abdominal radiography
  • may have air fluid levels
• upper GI imaging with barium enema
  • “bird beak” appearance at site of rotation
• failure of duodenum to cross midline = malrotation

Differential Diagnosis

• Intussusception 
• Intestinal atresia 
• Gastroenteritis
• Appendicitis 
• Meckel diverticulum 

Treatment

• Malrotation without volvulus
  • elective Ladd procedure
• Malrotation with volvulus (symptomatic or acute abdomen)
  • emergent endoscopic decompression
• surgical decompression

Prognosis, Prevention, and Complications

• Prognosis
  • good with treatment
• Complications
  • bowel necrosis
  • perforation
  • sepsis