Intestinal Volvulus Differential Diagnoses

  • Author: Andre Hebra, MD; Chief Editor: Carmen Cuffari, MD   more...
 
Updated: Jan 20, 2012
 
 

Diagnostic Considerations

The most significant problem is failure to recognize midgut volvulus in the differential diagnosis of a child with a history of bilious vomiting. One must remember that the signs and symptoms of an acute abdomen may be absent if intestinal ischemia and necrosis have not yet developed. Many devastating medical and legal complications can be prevented if this diagnosis is always considered in any patient with abdominal pain, bilious vomiting, and signs of intestinal obstruction.

The differential diagnosis of malrotation is that of high obstruction. If volvulus has occurred causing necrosis in the first week of life, necrotizing enterocolitis may be included in the differential. In older children, symptoms are often more subtle and chronic, and vomiting may be accompanied by alternating diarrhea and constipation. The differential diagnosis can then be expanded to include inflammatory bowel disease (IBD), gastroesophageal reflux disease (GERD), celiac disease, Crohn disease, and ulcerative colitis.

In the past, many children with malrotation were diagnosed with psychogenic vomiting. Upon diagnosis and surgical correction, all symptoms disappeared. This diagnostic omission is less likely today, but the example emphasizes the insidiousness of symptoms in older children and reminds physicians to consider the diagnosis in the differential for a child presenting with intermittent abdominal symptoms.

In addition to the differential diagnosis listed below, consider the following:

  • Duodenal stenosis
  • Duodenal web
  • Annular pancreas
  • Increased intracranial pressure (intracranial hemorrhage, hydrocephalus, intracranial mass)
  • Primary gastric atony
  • Bowel obstruction
  • Incarcerated hernia
  • Ovarian torsion
  • Pancreatitis
  • Peptic ulcer
  • Perforated viscus
  • Renal stones
  • Sickle cell crisis

Differential Diagnoses

Proceed to Workup
 
 
Contributor Information and Disclosures
Author

Andre Hebra, MD  Chief, Division of Pediatric Surgery, Professor of Surgery and Pediatrics, Medical University of South Carolina College of Medicine; Surgeon-in-Chief, Medical University of South Carolina Children's Hospital

Andre Hebra, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Children's Oncology Group, Florida Medical Association, International Pediatric Endosurgery Group, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons, South Carolina Medical Association, Southeastern Surgical Congress, and Southern Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Carmen Cuffari, MD  Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine

Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Additional Contributors

Liz D Dancel, MD Resident, Department of Pediatrics, Greenville Hospital System University Medical Center

Disclosure: Nothing to disclose.

Jeffrey J DuBois, MD Chief of Children's Surgical Services, Division of Pediatric Surgery, Kaiser Permanente, Women and Children's Center, Roseville Medical Center

Jeffrey J DuBois, MD, is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, and California Medical Association

Disclosure: Nothing to disclose.

Andre Hebra, MD Chief, Division of Pediatric Surgery, Professor of Surgery and Pediatrics, Medical University of South Carolina College of Medicine; Surgeon-in-Chief, Medical University of South Carolina Children's Hospital

Andre Hebra, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Children's Oncology Group, Florida Medical Association, International Pediatric Endosurgery Group, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons, South Carolina Medical Association,Southeastern Surgical Congress, and Southern Medical Association

Disclosure: Nothing to disclose.

B UK Li, MD Professor of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Director, Pediatric Fellowships and Gastroenterology Fellowship, Medical Director, Functional Gastrointestinal Disorders and Cyclic Vomiting Program, Medical College of Wisconsin; Attending Gastroenterologist, Children's Hospital of Wisconsin

B UK Li, MD is a member of the following medical societies: Alpha Omega Alpha, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Jonathan E Markowitz, MD Associate Professor of Clinical Pediatrics, University of South Carolina School of Medicine; Attending Pediatric Gastroenterologist, Associate Director of Pediatric Residency Program, Greenville Hospital System

Jonathan E Markowitz, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, Crohns and Colitis Foundation of America, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Melissa Miller, MD Department of Surgery, Medical University of South Carolina

Melissa Miller, MD is a member of the following medical societies: American Medical Association and American Medical Student Association/Foundation

Disclosure: Nothing to disclose.

Robert K Minkes, MD, PhD Professor of Surgery, University of Texas Southwestern Medical Center at Dallas, Southwestern Medical School; Medical Director and Chief of Surgical Services, Children's Medical Center of Dallas-Legacy Campus

Robert K Minkes, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, and Phi Beta Kappa

Disclosure: Nothing to disclose.

David A Piccoli, MD Chief of Pediatric Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia; Professor, University of Pennsylvania School of Medicine

David A Piccoli, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Marleta Reynolds, MD Professor of Surgery, Northwestern University, The Feinberg School of Medicine; Head, Department of Surgery and Surgeon in Chief, Head, Division of Pediatric Surgery, Children's Memorial Hospital of Chicago

Marleta Reynolds, MD is a member of the following medical societies: American Pediatric Surgical Association

Disclosure: Nothing to disclose.

Prem C Shukla, MD Associate Chairman, Associate Professor, Department of Emergency Medicine, University of Arkansas for Medical Sciences

Prem C Shukla, MD, is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

David E Wesson, MD Professor of Surgery, Professor of Pediatrics, Chief of Division of Pediatric Surgery, Michael E DeBakey Department of Surgery, Baylor College of Medicine; Chief of Pediatric Surgery Service, Texas Children's Hospital

David E Wesson, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Association for the Surgery of Trauma, American College of Physicians, American Pediatric Surgical Association, American Surgical Association, Canadian Association of Pediatric Surgeons, Children's Oncology Group, Eastern Association for the Surgery of Trauma, Society for Surgery of the Alimentary Tract,Society of University Surgeons, and Trauma Association of Canada

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

Additional Contributors

Liz D Dancel, MD Resident, Department of Pediatrics, Greenville Hospital System University Medical Center

Disclosure: Nothing to disclose.

Jeffrey J DuBois, MD Chief of Children's Surgical Services, Division of Pediatric Surgery, Kaiser Permanente, Women and Children's Center, Roseville Medical Center

Jeffrey J DuBois, MD, is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, and California Medical Association

Disclosure: Nothing to disclose.

Andre Hebra, MD Chief, Division of Pediatric Surgery, Professor of Surgery and Pediatrics, Medical University of South Carolina College of Medicine; Surgeon-in-Chief, Medical University of South Carolina Children's Hospital

Andre Hebra, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Children's Oncology Group, Florida Medical Association, International Pediatric Endosurgery Group, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons, South Carolina Medical Association,Southeastern Surgical Congress, and Southern Medical Association

Disclosure: Nothing to disclose.

B UK Li, MD Professor of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Director, Pediatric Fellowships and Gastroenterology Fellowship, Medical Director, Functional Gastrointestinal Disorders and Cyclic Vomiting Program, Medical College of Wisconsin; Attending Gastroenterologist, Children's Hospital of Wisconsin

B UK Li, MD is a member of the following medical societies: Alpha Omega Alpha, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Jonathan E Markowitz, MD Associate Professor of Clinical Pediatrics, University of South Carolina School of Medicine; Attending Pediatric Gastroenterologist, Associate Director of Pediatric Residency Program, Greenville Hospital System

Jonathan E Markowitz, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, Crohns and Colitis Foundation of America, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Melissa Miller, MD Department of Surgery, Medical University of South Carolina

Melissa Miller, MD is a member of the following medical societies: American Medical Association and American Medical Student Association/Foundation

Disclosure: Nothing to disclose.

Robert K Minkes, MD, PhD Professor of Surgery, University of Texas Southwestern Medical Center at Dallas, Southwestern Medical School; Medical Director and Chief of Surgical Services, Children's Medical Center of Dallas-Legacy Campus

Robert K Minkes, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, and Phi Beta Kappa

Disclosure: Nothing to disclose.

David A Piccoli, MD Chief of Pediatric Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia; Professor, University of Pennsylvania School of Medicine

David A Piccoli, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Marleta Reynolds, MD Professor of Surgery, Northwestern University, The Feinberg School of Medicine; Head, Department of Surgery and Surgeon in Chief, Head, Division of Pediatric Surgery, Children's Memorial Hospital of Chicago

Marleta Reynolds, MD is a member of the following medical societies: American Pediatric Surgical Association

Disclosure: Nothing to disclose.

Prem C Shukla, MD Associate Chairman, Associate Professor, Department of Emergency Medicine, University of Arkansas for Medical Sciences

Prem C Shukla, MD, is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

David E Wesson, MD Professor of Surgery, Professor of Pediatrics, Chief of Division of Pediatric Surgery, Michael E DeBakey Department of Surgery, Baylor College of Medicine; Chief of Pediatric Surgery Service, Texas Children's Hospital

David E Wesson, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Association for the Surgery of Trauma, American College of Physicians, American Pediatric Surgical Association, American Surgical Association, Canadian Association of Pediatric Surgeons, Children's Oncology Group, Eastern Association for the Surgery of Trauma, Society for Surgery of the Alimentary Tract,Society of University Surgeons, and Trauma Association of Canada

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

References
  1. Houshian S, Sørensen JS, Jensen KE. Volvulus of the transverse colon in children. J Pediatr Surg. Sep 1998;33(9):1399-401. [Medline].

  2. Reid J. Anatomical observations. Edinburgh M. & S. J. 1836;46:70.

  3. Mall FP. Development of the human intestine and its position in the adult. Bulletin of Johns Hopkins Hospital. 1898;9:197.

  4. Dott NM. Anomalies of intestinal rotation: Their embryology and surgical aspects with report of five cases. Brit J Surg. 1923;11:251.

  5. Ladd WE. Congenital obstruction of the duodenum in children. NEJM. 1932;206:277-83.

  6. Messineo A, MacMillan JH, Palder SB. Clinical factors affecting mortality in children with malrotation of the intestine. J Pediatr Surg. Oct 1992;27(10):1343-5. [Medline].

  7. Lesher AP, Dixon JA, Barbour JR, Hebra A. Recurrence of midgut volvulus after a Ladd procedure. Am Surg. Jan 2010;76(1):120-2. [Medline].

  8. Walker GM, Neilson A, Young D, Raine PA. Colour of bile vomiting in intestinal obstruction in the newborn: questionnaire study. BMJ. Jun 10 2006;332(7554):1363. [Medline]. [Full Text].

  9. Murphy MS. Management of bloody diarrhoea in children in primary care. BMJ. May 3 2008;336(7651):1010-5. [Medline]. [Full Text].

  10. Welte FJ, Grosso M. Left-sided appendicitis in a patient with congenital gastrointestinal malrotation: a case report. J Med Case Reports. Sep 19 2007;1:92. [Medline]. [Full Text].

  11. Ford EG, Senac MO Jr, Srikanth MS. Malrotation of the intestine in children. Ann Surg. Feb 1992;215(2):172-8. [Medline].

  12. Dufour D, Delaet MH, Dassonville M. Midgut malrotation, the reliability of sonographic diagnosis. Pediatr Radiol. 1992;22(1):21-3. [Medline].

  13. Jabra AA, Fishman EK. Small bowel obstruction in the pediatric patient: CT evaluation. Abdom Imaging. Sep-Oct 1997;22(5):466-70. [Medline].

  14. Hsiao M, Langer JC. Value of laparoscopy in children with a suspected rotation abnormality on imaging. J Pediatr Surg. Jul 2011;46(7):1347-52. [Medline].

  15. Bax NM, van der Zee DC. Laparoscopic treatment of intestinal malrotation in children. Surg Endosc. Nov 1998;12(11):1314-6. [Medline].

  16. Hagendoorn J, Vieira-Travassos D, van der Zee D. Laparoscopic treatment of intestinal malrotation in neonates and infants: retrospective study. Surg Endosc. Jan 2011;25(1):217-20. [Medline]. [Full Text].

  17. Bill A, Grauman D. Rationale and technic for stabilization of the mesentery in cases of nonrotation of the midgut. J Pediatr Surg. 1966;1:127-36.

  18. Gohl ML, DeMeester TR. Midgut nonrotation in adults. An aggressive approach. Am J Surg. Mar 1975;129(3):319-23. [Medline].

Previous
Next
 
Upper GI contrast study in a 10-year-old patient with intestinal malrotation. Note normal appearance of stomach but abnormal shape of duodenum. Duodenum does not have C-loop appearance, it does not cross back over midline (spine), and proximal jejunum is located on right side of abdomen. In addition, this patient had partial volvulus illustrated by corkscrew appearance of duodenum.
Upper GI contrast study of full-term newborn baby with bilious vomiting. Note obstruction at third and fourth portions of duodenum with "bird's-beak" appearance, which is compatible with midgut volvulus and malrotation.
Barium enema of 1-year-old infant with history of intermittent bilious vomiting. Colon is positioned abnormally, with most of it on left side of abdomen. Note cecum and terminal ileum in left upper quadrant of abdomen.
CT scan of 4-year-old patient with intermittent episodes of bilious vomiting. CT scan was performed at time of volvulation of the midgut. Note whirl or swirl appearance in midabdomen at site of narrow pedicle of superior mesenteric artery, which is compatible with acute twist observed during midgut volvulus.
Operative photograph illustrating midgut volvulus of full-term newborn who underwent upper GI contrast study. Note complete twist (> 360°) of entire small bowel over narrow pedicle of its mesentery. Note appearance of small bowel and congestion and cyanosis due to vascular compromise from volvulus. Fortunately, early operative intervention prevented development of necrosis, and emergent untwisting combined with Ladd procedure was successful.
Operative photograph of midgut volvulus due to intestinal malrotation in 10-year-old patient. Note twisting at base of mesentery with evidence of intestinal congestion and ischemia but no necrosis.
Diagram illustrating operative maneuver to untwist volvulized midgut. Note that untwisting is performed in counterclockwise fashion by operating surgeon. Once this is accomplished, Ladd procedure is completed by dividing any obstructing bands and by broadening base of mesentery.
Operative photograph of patient with midgut volvulus in which diagnosis was made late. Note that entire small bowel is necrotic and nonviable. This infant did not survive.
Operative findings of malrotation of gut with volvulus.
Plain abdominal radiograph shows dilated stomach and proximal bowel with some air distally (ie, double-bubble sign).
Lateral view from upper GI series reveals duodenum with corkscrew appearance.
Upper GI series of child with malrotation and midgut volvulus that reveals abnormal position and obstruction in third part of duodenum.
Barium enema in child with malrotation and midgut volvulus. Note cecum in right upper quadrant and dilated loops of small bowel.
Ultrasound image with Doppler flow revealing twisted superior mesenteric artery and vein in child with midgut volvulus.
CT scan of abdomen in child with midgut volvulus. Note twisted mesentery and bowel anterior to right kidney.
Malrotation and midgut volvulus with intestinal ischemia. Note narrow pedicle at base of mesentery. No resection was required since ischemic necrosis had not yet developed.
Malrotation and midgut volvulus with intestinal necrosis. Massive resection of small bowel was required, but child survived and was eventually weaned off total parenteral nutrition.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.