Updated: 9/27/2022

Volvulus

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  • Snapshot
    • A 10-day-old baby boy is brought to the emergency room for repeated episodes of vomiting. His mother describes the vomit as green and yellow. On physical exam, the physician has difficulty at first locating the heartbeat, but finally hears a heartbeat on the right side of the chest. Suspicious, he sends the baby for abdominal radiography and upper GI series. Imaging reveals dilated bowel loops and a “birds beak” appearance of bowel.
  • Introduction
    • Malrotation 
      • errors during development
      • increases risk of midgut volvulus
        • 1/3 of children with malrotation develop volvulus
    • Midgut volvulus
      • abnormal rotation of bowel due to pathologic adhesions fixating the bowel around itself
        • twists around SMA
        • compromises blood flow to bowel
      • majority in ileum
      • increased risk of bowel necrosis and perforation
    • Cecal volvulus
      • common in young, active patients
      • "coffee bean" sign
    • Associated conditions
      • gastroschisis
      • omphalocele
      • situs inversus
      • cardiovascular defects
      • Hirschsprung disease
      • heterotaxy
    • Malrotation with midgut volvulus is a surgical emergency
  • Epidemiology
    • Most common in newborns
    • Males > females
    • 80% of cases are newborn
    • Elderly population can have malrotation, but volvulus is less often
  • Presentation
    • Symptoms
      • neonates (majority of patients)
        • bilious vomiting within first week of life
        • colicky pain
      • older patients
        • nonbilious vomiting
        • crampy abdominal pain
        • change in bowel pattern
        • nausea
    • Physical exam
      • abdominal distention
      • abdominal tenderness
      • acute abdomen
      • shock
  • Imaging
    • Abdominal radiography
      • multiple air fluid levels
      • dilated loops of bowel with loss of haustra
      • normal radiography does not exclude disease
    • Upper GI imaging with barium enema
      • “bird beak” appearance at site of rotation
      • “coffee bean” appearance of bowel
      • failure of duodenum to cross midline = malrotation
  • Differential Diagnosis
    • Intussusception
    • Intestinal atresia
  • Treatment
    • Malrotation without volvulus
      • elective Ladd procedure
    • Malrotation with volvulus (symptomatic or acute abdomen)
      • emergent endoscopic decompression
      • emergent surgical decompression
  • PREVENTION
    • Prevention
      • if patient has heterotaxy, screen for malrotation
      • elective Ladd procedure if malrotation without volvulus
  • Complications
    • Bowel necrosis and perforation
    • Sepsis
  • Prognosis
    • Most with resolution of symptoms after surgery
    • Good prognosis
      • mortality rate 3-9%, worse with
        • premature neonates
        • bowel necrosis
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(M2.GI.17.4688) A 5 day old neonate presents at night to the emergency room with "one day of green vomiting and a larger belly than usual" according to mom. The mother explains that the patient passed stool for only two days after birth and had been feeding well until this morning when the patient vomited after feeding and continued to vomit sporadically throughout the day. Newborn screening was normal for this patient, there were no pregnancy complications, the patient has been breastfeeding consistently with only some regurgitation, and the patient has no sick contacts. The abdomen is distended on physical exam without palpable masses, and there is no stool in the rectal vault. Upper gastrointestinal series film can be appreciated in Figure A. What is the most likely diagnosis of this patient?

QID: 107531
FIGURES:

Duodenal Atresia

12%

(1/8)

Mid-gut Volvulus

50%

(4/8)

Pyloric Stenosis

12%

(1/8)

Biliary Atresia

25%

(2/8)

Meconium Ileus

0%

(0/8)

M 6 B

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(M3.GI.16.44) A 73-year-old woman with a history of diabetes presents to the emergency department with severe abdominal pain and constipation for 24 hours. Vital signs are T: 100.3 F, HR: 80 bpm, BP: 143/82 mmHg, RR: 24/min, O2 Sat: 95%. Abdominal exam is notable for diffuse abdominal tenderness to palpation, without rebound or guarding. Laboratory studies are notable for leukocytosis, though lactic acid is within normal limits. Abdominal x-ray is shown in Figure A. Which of the following are the best next management steps for this patient?

QID: 103067
FIGURES:

Sigmoidoscopy and placement of a rectal tube for 48-72 hours

33%

(4/12)

Barium Enema with abdominal xray

17%

(2/12)

Immediate laparotomy with Hartmann's procedure

25%

(3/12)

Immediate laparotomy with sigmoidectomy and primary anastomosis

8%

(1/12)

NPO, NG tube decompression and neostigmine

17%

(2/12)

M 11 E

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(M2.GI.15.6409) A 74-year-old female presents to the emergency room with abdominal pain. She notes several days of constipation and most recently has not had a bowel movement in 3 days. She is unable to remember if she has passed gas. Her vital signs are BP 118/76 mmHg, HR 97 beats per minute, RR 17 breaths per minute, and T 99.4 degrees Fahrenheit, and her abdomen is noticeably distended. A barium enema radiograph is shown in Figure A. Which of the following is the best next step?

QID: 106964
FIGURES:

Manual evacuation of rectal impaction

41%

(36/87)

Administer large doses of laxatives

7%

(6/87)

Laparotomy with sigmoid resection

17%

(15/87)

Proctosigmoidoscopy and placement of a rectal tube

29%

(25/87)

Observation

5%

(4/87)

M 7 E

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Evidence (3)
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