eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology

Intestinal Volvulus: Treatment & Medication

Author: Andre Hebra, MD, Chief, Division of Pediatric Surgery, Medical University of South Carolina; Professor of Surgery and Pediatrics, Medical University of South Carolina
Coauthor(s): Melissa Miller, MD, Department of Surgery, Medical University of South Carolina
Contributor Information and Disclosures

Updated: Sep 11, 2008

Treatment

Medical Care

The definitive treatment of malrotation and intestinal volvulus is surgical correction. Medical care revolves around support of the patient preoperatively and postoperatively, treatment and/or stabilization of any coexisting conditions, and expedition of transport to the operating room.

Of note, nonoperative treatment might be appropriate for older patients that have intestinal malrotation and are truly asymptomatic. However, the patient and the family must be made aware of the fact that intestinal volvulus may occur at any time and that they need to seek immediate medical attention if any GI symptoms develop.

• Insertion of a nasogastric or orogastric tube begins GI decompression.
• Support the respiratory system with intubation and ventilation as needed.
• Prophylactic broad-spectrum antibiotics are administered and continued postoperatively if the bowel vascular supply is compromised, causing necrosis.
• Closely monitor fluid and electrolyte status, with intravenous fluids administered at least at maintenance levels and increased for any signs of dehydration and/or fluid shifts.
• Electrolytes are aggressively replaced.
• Foley catheter placement may be appropriate, especially in older children.
• In addition, if volvulus has not yet occurred, closely monitor for acute changes in symptoms (eg, vomiting, distension, fever, hemodynamic instability), which may show that volvulus has occurred.

Surgical Care

The basis of surgical correction of malrotation is to free obstruction and to widen the base of mesenteric attachment. Several approaches were attempted with some success before Ladd first described a reliable technique in 1932. His approach placed the intestines in a prior embryological state but accomplished the greatest stability to that point. His procedure survives, relatively unchanged, as the most widely used technique.

• Ladd procedure
  • The Ladd procedure uses a transverse incision through the right rectus muscle in the right upper quadrant. This incision allows the greatest visualization and access to the anatomy.
  • The surgeon must quickly explore the anatomical defect and then completely eviscerate the midgut.
  • Chylous ascites is occasionally present. This turbid fluid may appear infected but is actually sterile.
  • In most patients, volvulus is corrected by rotating the small intestine in a counterclockwise direction (see Media file 7).
  • Thoroughly examine the bowel for signs of necrosis and cover the bowel with warm sponges while correcting malrotation to allow restoration of blood flow.
  • The surgeon should dissect the SMA pedicle of any constricting peritoneal attachment all the way to the pancreas to facilitate the widening of the pedicle. Ladd bands, which constrict the duodenum, are thoroughly divided, using a Kocher maneuver to ensure resolution of restriction.
  • The cecum is placed in the left abdomen, and the duodenum is directed down the right paravertebral gutter.
  • Closing or widening any defect to prevent future strangulation can repair mesocolic hernias.
  • Appendectomy is performed in the absence of cecal necrosis and/or the placement of prosthetic material, preventing later confusion in diagnosing appendicitis. At this point, conservatively resect the necrotic bowel, leaving questionable bowel in situ, because edematous and ischemic bowel may regain function over the next few days.
  • A second-look laparotomy may be used 36 hours later to ensure viability of the remaining bowel.
  • Focus all efforts on leaving most of the bowel intact if possible because necrosis and resection of large amounts of bowel cause long-term nutritional problems and may lead to death.
  • In the tragic case of total midgut infarction, close the abdomen with the entire bowel intact, and provide terminal care. Assure duodenal patency before closure.
  • Many techniques have been used, such as the injection of air and saline, but the most successful approach is the use of a large Fogarty embolectomy catheter or other appropriately sized balloon-tipped catheter. The catheter is placed orogastrically or nasogastrically and passed through the duodenum. Then, the balloon is inflated and retracted through the duodenum. Atresia prevents the complete passage of the catheter, while stenosis or a duodenal web or diaphragm causes tension on the intestinal wall upon retraction of the catheter.
  • Transluminal repair of any obstruction is preferred if possible, or resection with end-to-end reanastomosis is performed.
• Abdominal closure
  • If the abdominal wall cannot be closed without causing abdominal compartment syndrome, a silo may be placed for temporary closure. This technique has been used with some significant success.
  • Edematous bowel may place excessive pressure on the diaphragm, great vessels, and kidneys, causing hemodynamic, respiratory, and renal compromise.
  • A silo optimizes cardiorespiratory status while optimizing blood flow through the SMA. Additionally, the silo may allow a bedside second-look, thus decreasing expenses and transport, which is especially pertinent in the care of premature neonates.
  • Surgeons must use clinical judgment in the assessment of abdominal pressures for the purpose of silo application.
• Role of laparoscopy
  • A laparoscopic variation of the Ladd procedure has been used in some centers, with the general advantage of decreased scarring and adhesions; however, good visualization of the entire bowel is vital to the accurate resection or preservation of ischemic bowel, and a laparoscopic approach impairs full examination of the intestine.
  • Although adhesions may create obstructive problems in 1-10% of patients, they may also provide stability to the new intestinal placement.
• Role of surgical fixation during the Ladd procedure
  • The 7% recurrence rate of volvulus after the Ladd procedure has encouraged surgeons to attempt fixation of the cecum and/or duodenum. In 1966, Bill reported successful results with fixation of the cecum in the left lower quadrant with and without duodenal fixation.⁷
  • Other authors have argued that volvulus recurrence rates remain unchanged, and that continued abdominal symptoms are more common after fixation; therefore, in general, cecal and duodenal fixation are not widely used today. Applications may be noted; in 1992, Ford et al used colopexy and duodenopexy only in rare cases of persistent narrow SMA pedicle despite dissection of peritoneal attachments with good results.⁵
  • In 1975, Gohl and DeMeester used the less well-known Fitzgerald technique with good results in adults.⁸ This approach places the bowel in the mature anatomic position. The abdomen is entered through a midline incision. The surgeon then lyses bands and peritoneal attachments to mobilize the bowel. A new retroperitoneal bed is created in the right paravertebral gutter for the placement of the ascending colon, which is then secured laterally. The small bowel is pulled under the base of the colonic mesentery, with fixation of the duodenum medially and a new ligament of Treitz at the duodenal exit beneath the transverse mesocolon. Historically, most authors have reported difficulty with the creation of a new ligament of Treitz of the proper tension. Fixation may also contribute to continued symptoms.
• Management of other associated anomalies
  • Coexisting conditions may complicate clinical decisions. Stabilize congenital heart defects before the Ladd procedure in the absence of ischemic volvulus.
  • In the case of malrotation and Hirschsprung disease, surgery is also delayed, if possible, until a simultaneous pull-through can be accomplished. In these cases, educate patients and parents on obstructive symptoms.
  • In Waugh syndrome, intussusception can often be reduced with contrast enema. The Ladd procedure actually adds to hospital stay and expenses, and it appears inefficient. However, intussusception is likely to recur if the anatomical defect remains.
  • Abdominal wall defects may contribute to thickening and shortening of the bowel, making anatomical identification and correction difficult.
• Postoperative care
  • This depends on the presence of other abnormalities, which should be treated accordingly, and the presence of necrotic bowel.
  • If necrosis and resection have occurred, nutritional support becomes an integral part of medical care. Total parenteral nutrition is needed acutely and may be continued long term.
  • The patient needs close monitoring for several days after surgery because questionable bowel may recover or become necrotic.
  • In addition, the occurrence of volvulus, although low in incidence, remains a possibility.
  • Any signs and symptoms of obstruction should be noted by physicians and family members and attended to quickly.

Consultations

• Involve a pediatric surgeon early in the care of a patient suspected to have malrotation or intestinal volvulus.
• The surgeon, pediatrician, and an experienced radiologist should be directly involved in the performance of imaging studies.
• In the case of volvulus, rapid procession to the operating room may be necessary, and all facilitating measures should be taken.

Diet

• The determination of diet postoperatively depends on the degree of bowel distress. Markedly edematous bowel may take longer to recuperate, delaying the tolerance of oral feeds.
• Total parenteral feeds may be necessary in the interim period.
• In addition, necrosis of the bowel necessitates removal. If a significant portion of the bowel is removed, the child may develop short-bowel syndrome. This condition requires a lifetime of dietary modifications and possibly long-term hyperalimentation supplementation.
• However, in the absence of complicating factors, feeding can resume as soon as the bowel recovers and toleration begins.
• No special diet is required.

Activity

No specific restrictions regarding postoperative activity are indicated. Age-appropriate activity is always encouraged as soon as tolerated after surgery, barring other restricting abnormalities.

Medication

No medical therapy is indicated in the management of malrotation and intestinal volvulus. Treatment is surgical correction. Observation may be used in the patient for whom surgery is not appropriate (eg, awaiting the stabilization of congenital heart defects). Broad-spectrum antibiotics are used preoperatively (postoperatively, if needed) and should be chosen to cover both skin and enteric flora.

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