Pediatric emergency medicine trisk 3762 3762

Volvulus is the most serious etiology of intestinal obstruction
Neonates with bilious emesis should be emergently evaluated for
malrotation and volvulus even if well-appearing
Sudden onset of abdominal pain and bilious emesis in a child should
prompt rapid evaluation for midgut volvulus
Current Evidence
Malrotation of the bowel is a congenital condition associated with abnormal
fixation of the mesentery of the bowel ( Fig. 116.9 ). Therefore, the bowel has a
tendency to volvulize and obstruct at points of abnormal fixation. Although
malrotation with volvulus usually occurs either in utero or during early neonatal
life, malrotation can be unrecognized until childhood (25% of cases present after
1 year of age). This is an extraordinarily dangerous situation because a complete
volvulus of the bowel for more than an hour or two can obstruct blood supply to
the bowel completely, leading to complete necrosis of the involved segment.
When a volvulus involves the midgut, the entire small bowel and ascending colon
may be lost. To prevent such a catastrophe, physicians should have a high index
of suspicion for malrotation in any child with signs of obstruction and be
prepared to get a child with a presumed volvulus to the operating room
immediately.
Clinical Considerations
Initial Assessment. Any child with bilious vomiting and abdominal pain may
have malrotation with volvulus. The pain is usually intense and constant,
although infants with early volvulus may initially appear well. Blood may appear
in the stool within a few hours and suggests the development of ischemia and
possible necrosis of the bowel. Clinically, malrotation can present in several
different ways: first, and most dangerous, is the sudden onset of abdominal pain
with bilious vomiting with no prior history of GI problems; second is a similar
abrupt onset of obstruction in a child who previously seemed to have “feeding
problems” with transient episodes of bilious vomiting; and third is a child with
failure to thrive because of alleged intolerance of feedings.