Review Question - QID 214407

This patient likely has intestinal malrotation with volvulus as demonstrated by bilious emesis, abdominal tenderness, and positive radiograph findings (i.e., prominent loops of gas-filled small bowel).

Intestinal malrotation is a congenital anomaly that results from an arrest of normal rotation of the midgut during development. Anomalies may include small intestine that is found predominantly on the right side of the abdomen, displaced cecum, absent or displaced ligament of Treitz, or narrow mesentery. These abnormalities may lead to volvulus, which is when a loop of intestine twists around itself and the mesentery, resulting in bowel obstruction. Patients commonly present with bilious vomiting, abdominal pain, abdominal distension, and sometimes hematochezia. However, it is worth noting that patients without acute volvulus may be asymptomatic. Bilious vomiting in a child younger than 1 year of age should immediately raise suspicion for malrotation with possible volvulus. Diagnosis usually begins with an abdominal radiograph to rule out perforation and is confirmed via an upper GI series. Treatment involves surgery with the Ladd procedure. In a patient with suspected volvulus, immediate laparotomy with surgical exploration is indicated.

Figure/Illustration A is an abdominal radiograph with several air-filled loops of the small bowel (circle) and no gas at the rectum suggestive of intestinal obstruction (arrow).

Incorrect Answers:
Answer 2: Intussusception is a condition in which 1 segment of intestine telescopes inside of another segment. Patients can present with similar symptoms such as vomiting, abdominal pain, and bloody stool. However, these "attacks" are more intermittent rather than a constant period of projectile emesis.

Answer 3: Necrotizing enterocolitis is a medical condition where a portion of the bowel dies. Typical symptoms often include feeding intolerance, failure to thrive, abdominal distension, and bloody stools. However, this condition is commonly seen in premature infants and is uncommon in an otherwise healthy 1-month-old infant.

Answer 4: Pyloric stenosis describes the narrowing of the pylorus. Symptoms often present within the first week to month of life with progressively worsening, often projectile vomiting. Episodes commonly follow feeds and are usually non-bilious. This patient’s bilious projectile vomiting is more suggestive of intestinal malrotation.

Answer 5: Viral infection can lead to emesis. However, enteric viral infections often present with both emesis and diarrhea. This patient’s lack of sick contacts and the presence of bilious emesis should raise suspicion for intestinal malrotation.

Bullet Summary:
Bilious emesis in a child younger than 1 year of age should raise suspicion for intestinal malrotation with volvulus.