eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology

Volvulus: Differential Diagnoses & Workup

Author: 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
Coauthor(s): Liz D Dancel, MD, Intern, Department of Pediatrics, Greenville Hospital System University Medical Center; Prem C Shukla, MD, Associate Chairman, Associate Professor, Department of Emergency Medicine, University of Arkansas for Medical Sciences
Contributor Information and Disclosures

Updated: May 13, 2008

Differential Diagnoses

Cholecystitis
Intussusception
Constipation
Meckel Diverticulum
Gastroenteritis
Hepatitis B
Hirschsprung Disease

Other Problems to Be Considered

Appendicitis
Bowel obstruction
Colic
Henoch-Schönlein purpura
Incarcerated hernia
Necrotizing enterocolitis
Ovarian torsion
Pancreatitis
Peptic ulcer
Perforated viscus
Renal stones
Sickle cell crisis
Urinary tract infection

Workup

Laboratory Studies

  • Laboratory tests should not delay immediate surgical consultation and operation when volvulus is suspected; no laboratory tests are specific for this problem.  
  • A CBC count, clotting studies, electrolyte level tests, and blood glucose level tests are usually sufficient for preoperative evaluation.

Imaging Studies

  • Plain radiography
    • Flat, upright, and cross-table lateral radiographs of the abdomen may reveal evidence of small bowel obstruction, including dilated small-bowel loops; marked gastric or proximal duodenal dilatation, with or without intestinal gas; and air-fluid levels.
    • The double bubble sign, indicative of gastric and duodenal dilatation, can be demonstrated on a simple air contrast study (see Media file 1).
    • In early cases, plain abdominal radiography may not be helpful, but oral contrast studies may reveal intestinal obstruction.
    • In contrast to midgut volvulus, plain radiography may reveal a distended sigmoid colon characteristic to sigmoid volvulus. 
  • Upper GI imaging
    • Although the issue of upper versus lower GI contrast studies is controversial, most centers prefer upper GI imaging (UGI) series for the radiologic evaluation of malrotation and midgut volvulus.
    • In patients who are stable, most centers perform an UGI series.
    • Malrotation with midgut volvulus is suspected when the duodenojejunal junction is in an abnormal location and/or an abrupt ending or corkscrew tapering of contrast is present, signifying proximal intestinal obstruction (see Media file 2).
    • Specificity of UGI studies in detecting malrotation is 100%, but the sensitivity for detecting midgut volvulus is only 54%, reflecting the importance of clinical judgment in diagnosis.
  • Lower GI imaging
    • When the results of UGI studies are equivocal, a lower GI imaging (LGI) contrast study may be used to identify malrotation. However, the results are not reliable if a midgut volvulus is present.
    • In patients with bilious vomiting and a low clinical suspicion for midgut volvulus, LGI may be used to rule out colonic obstruction due to conditions such as atresia, Hirschsprung disease, and meconium ileus and/or meconium plug and may actually prove to be therapeutic.
    • Important findings on LGI include demonstration of the cecum and proximal colon in the left flank.
    • Failure to recognize malrotation has been observed with LGI studies in 5-20% of patients with a normally located cecum.
    • LGI reveals dilated rectosigmoid loops with an abrupt inability to pass contrast beyond obstruction in patients with sigmoid volvulus.
  • Ultrasonography
    • Usually, this test is not very helpful in evaluating patients.
    • In some cases, ultrasonography may reveal intraluminal fluid or edema in the bowel wall. If performed for other reasons, it may reveal persistent distension of the duodenum as it courses around the head of the pancreas.
    • In many patients with malrotation, the normal anatomical relationship between the SMA and vein is altered, and the artery lies anterior or even to the right of the superior mesenteric vein. On the other hand, a normal anatomical relationship between these structures does not rule out the possibility of malrotation.
  • CT scanning
    • Abdominal contrast CT has a high sensitivity for demonstrating small bowel obstruction.2
    • The finding of multiple and posterior location of transition points within the small bowel (segments where dilated small bowel is immediately followed by collapsed bowel) is predictive of volvulus.
    • The "whirl sign" (clockwise or counterclockwise twisting of the bowel that extends for at least 180 º) can also be seen using CT scanning in cases of volvulus.

More on Volvulus

Overview: Volvulus
Differential Diagnoses & Workup: Volvulus
Treatment & Medication: Volvulus
Follow-up: Volvulus
Multimedia: Volvulus
References
Further Reading
[ CLOSE WINDOW ]

References

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

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

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

  4. 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].

  5. Ameh EA, Nmadu PT. Intestinal volvulus: aetiology, morbidity, and mortality in Nigerian children. Pediatr Surg Int. 2000;16(1-2):50-2. [Medline].

  6. Anatol TI. Intestinal malrotation in Trinidad. J R Coll Surg Edinb. Jun 1992;37(3):172-4. [Medline].

  7. Andersen JF, Eklof O, Thomasson B. Large bowel volvulus in children. Review of a case material and the literature. Pediatr Radiol. 1981;11(3):129-38. [Medline].

  8. Andrassy RJ, Mahour GH. Malrotation of the midgut in infants and children: a 25-year review. Arch Surg. Feb 1981;116(2):158-60. [Medline].

  9. Black PR, Mueller D, Crow J. Mesenteric defects as a cause of intestinal volvulus without malrotation and as the possible primary etiology of intestinal atresia. J Pediatr Surg. Oct 1994;29(10):1339-43. [Medline].

  10. Bonadio WA, Clarkson T, Naus J. The clinical features of children with malrotation of the intestine. Pediatr Emerg Care. Dec 1991;7(6):348-9. [Medline].

  11. Boulton JE, Ein SH, Reilly BJ. Necrotizing enterocolitis and volvulus in the premature neonate. J Pediatr Surg. Sep 1989;24(9):901-5. [Medline].

  12. de Agustin JC, Vazquez JJ, Rodriguez-Arnao D. Severe short-bowel syndrome in children. Clinical experience. Eur J Pediatr Surg. Aug 1999;9(4):236-41. [Medline].

  13. Ditchfield MR, Hutson JM. Intestinal rotational abnormalities in polysplenia and asplenia syndromes. Pediatr Radiol. May 1998;28(5):303-6. [Medline].

  14. Feitz R, Vos A. Malrotation: the postoperative period. J Pediatr Surg. Sep 1997;32(9):1322-4. [Medline].

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

  16. Gambarara M, Ferretti F, Bagolan P. Ultra-short-bowel syndrome is not an absolute indication to small-bowel transplantation in childhood. Eur J Pediatr Surg. Aug 1999;9(4):267-70. [Medline].

  17. Gauderer MW. Acute abdomen. When to operate immediately and when to observe. Semin Pediatr Surg. May 1997;6(2):74-80. [Medline].

  18. Goulet OJ, Revillon Y, Jan D. Neonatal short bowel syndrome. J Pediatr. Jul 1991;119(1 ( Pt 1)):18-23. [Medline].

  19. Houben CH, Hiorns MP. Re: "Is ultrasonography a good screening test for intestinal malrotation?" by Orzech et al. J Pediatr Surg. Oct 2007;42(10):1795. [Medline].

  20. Ikeda H, Matsuyama S, Suzuki N. Small bowel obstruction in children: review of 10 years experience. Acta Paediatr Jpn. Dec 1993;35(6):504-7. [Medline].

  21. Ismail A. Recurrent colonic volvulus in children. J Pediatr Surg. Dec 1997;32(12):1739-42. [Medline].

  22. Kalfa N, Zamfir C, Lopez M. Conditions required for laparoscopic repair of subacute volvulus of the midgut in neonates with intestinal malrotation: 5 cases. Surg Endosc. Dec 2004;18(12):1815-7. [Medline].

  23. Kealey WD, McCallion WA, Brown S. Midgut volvulus in children. Br J Surg. Jan 1996;83(1):105-6. [Medline].

  24. Liu KK, Leung MW, Wong BP, Chao NS, Chung KW, Kwok WK. Minimal access surgery for sigmoid volvulus in children. Pediatr Surg Int. Dec 2006;22(12):1007-8. [Medline].

  25. Long FR, Kramer SS, Markowitz RI. Radiographic patterns of intestinal malrotation in children. Radiographics. May 1996;16(3):547-56; discussion 556-60. [Medline].

  26. Malek MM, Burd RS. Surgical treatment of malrotation after infancy: a population-based study. J Pediatr Surg. Jan 2005;40(1):285-9. [Medline].

  27. Matsuo Y, Nezu R, Kubota A. Massive small bowel resection in neonates--is weaning from parenteral nutrition the final goal?. Surg Today. 1992;22(1):40-5. [Medline].

  28. Maung M, Saing H. Intestinal volvulus: an experience in a developing country. J Pediatr Surg. May 1995;30(5):679-81. [Medline].

  29. Maxson RT, Franklin PA, Wagner CW. Malrotation in the older child: surgical management, treatment, and outcome. Am Surg. Feb 1995;61(2):135-8. [Medline].

  30. McVay MR, Kokoska ER, Jackson RJ, Smith SD. Jack Barney Award. The changing spectrum of intestinal malrotation: diagnosis and management. Am J Surg. Dec 2007;194(6):712-7; discussion 718-9. [Medline].

  31. Mellor MF, Drake DG. Colonic volvulus in children: value of barium enema for diagnosis and treatment in 14 children. AJR Am J Roentgenol. May 1994;162(5):1157-9. [Medline].

  32. Neilson IR, Youssef S. Delayed presentation of Hirschsprung's disease: acute obstruction secondary to megacolon with transverse colonic volvulus. J Pediatr Surg. Nov 1990;25(11):1177-9. [Medline].

  33. Palanivelu C, Rangarajan M, Shetty AR, Jani K. Intestinal malrotation with midgut volvulus presenting as acute abdomen in children: value of diagnostic and therapeutic laparoscopy. J Laparoendosc Adv Surg Tech A. Aug 2007;17(4):490-2. [Medline].

  34. Powell DM, Othersen HB, Smith CD. Malrotation of the intestines in children: the effect of age on presentation and therapy. J Pediatr Surg. Aug 1989;24(8):777-80. [Medline].

  35. Prasil P, Flageole H, Shaw KS. Should malrotation in children be treated differently according to age?. J Pediatr Surg. May 2000;35(5):756-8. [Medline].

  36. Rescorla FJ, Shedd FJ, Grosfeld JL. Anomalies of intestinal rotation in childhood: analysis of 447 cases. Surgery. Oct 1990;108(4):710-5; discussion 715-6. [Medline].

  37. Salas S, Angel CA, Salas N. Sigmoid volvulus in children and adolescents. J Am Coll Surg. Jun 2000;190(6):717-23. [Medline].

  38. Samuel M, Wheeler RA, Mami AG. Does duodenal atresia and stenosis prevent midgut volvulus in malrotation?. Eur J Pediatr Surg. Feb 1997;7(1):11-2. [Medline].

  39. Sandhu PS, Joe BN, Coakley FV, Qayyum A, Webb EM, Yeh BM. Bowel transition points: multiplicity and posterior location at CT are associated with small-bowel volvulus. Radiology. Oct 2007;245(1):160-7. [Medline].

  40. Seashore JH, Touloukian RJ. Midgut volvulus. An ever-present threat. Arch Pediatr Adolesc Med. Jan 1994;148(1):43-6. [Medline].

  41. Senocak ME, Buyukpamukcu N, Hicsonmez A. Massive paraesophageal hiatus hernia containing colon and stomach with organo-axial volvulus in a child. Turk J Pediatr. Jan-Mar 1990;32(1):53-8. [Medline].

  42. Shimanuki Y, Aihara T, Takano H. Clockwise whirlpool sign at color Doppler US: an objective and definite sign of midgut volvulus. Radiology. Apr 1996;199(1):261-4. [Medline].

  43. Siegel MJ, Shackelford GD, McAlister WH. Small bowel volvulus in children: its appearance on the barium enema examination. Pediatr Radiol. Nov 1980;10(2):91-3. [Medline].

  44. Smith SD, Golladay ES, Wagner C. Sigmoid volvulus in childhood. South Med J. Jul 1990;83(7):778-81. [Medline].

  45. Stauffer UG, Herrmann P. Comparison of late results in patients with corrected intestinal malrotation with and without fixation of the mesentery. J Pediatr Surg. Feb 1980;15(1):9-12. [Medline].

  46. Sule AZ, Misauno M, Opaluwa AS, Ojo E, Obekpa PO. One stage procedure in the management of acute sigmoid volvulus without colonic lavage. Surgeon. Oct 2007;5(5):268-70. [Medline].

  47. Tabassum HM, Ch MA, Bukhari MA. Small bowel volvulus leading to gangrene and short bowel syndrome. J Coll Physicians Surg Pak. Jan 2005;15(1):55-6. [Medline].

  48. Torres AM, Ziegler MM. Malrotation of the intestine. World J Surg. May-Jun 1993;17(3):326-31. [Medline].

  49. Uba AF, Chirdan LB, Edino ST. Intestinal malrotation: presentation in the older child. Niger J Med. Jan-Mar 2005;14(1):23-6. [Medline].

  50. Waldhausen JH, Sawin RS. Laparoscopic Ladd's procedure and assessment of malrotation. J Laparoendosc Surg. Mar 1996;6 Suppl 1:S103-5. [Medline].

  51. Waseem M, Hipp A. Megacolon: constipation or volvulus?. Pediatr Emerg Care. May 2006;22(5):346-8. [Medline].

  52. Weber TR, Tracy T Jr, Connors RH. Short-bowel syndrome in children. Quality of life in an era of improved survival. Arch Surg. Jul 1991;126(7):841-6. [Medline].

  53. Wiersma R, Hadley GP. Small bowel volvulus complicating intestinal ascariasis in children. Br J Surg. Jan 1988;75(1):86-7. [Medline].

  54. Yamashita H, Kato H, Uyama S. Laparoscopic repair of intestinal malrotation complicated by midgut volvulus. Surg Endosc. Nov 1999;13(11):1160-2. [Medline].

[ CLOSE WINDOW ]

Further Reading

For more information, see the eMedicine article Sigmoid Volvulus.

[ CLOSE WINDOW ]

Keywords

midgut volvulus, intestinal malrotation, superior mesenteric artery, SMA, midgut, rotational abnormality, extracoelomic elongation, duodenal loop, cecocolic loop, Ladd bands, sigmoid volvulus, duodenal atresia, Meckel diverticulum, intussusception, small bowel atresia, prune belly syndrome, gastric volvulus, persistent cloaca, Hirschsprung disease, extrahepatic biliary anomalies, Chagas disease, feeding intolerance, failure to thrive, constipation, bloody diarrhea, hematemesis, irritable bowel syndrome, peptic ulcer disease, kidney stones, peritonitis, hematochezia, ischemia, gangrene, intestinal ischemia, necrosis, abdominal distension, hypovolemia, septic shock

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

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.

Coauthor(s)

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

Medical Editor

Jeffrey J DuBois, MD, Consulting Staff, Division of Pediatric Surgery, Kaiser Permanente, North Sacramento 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, Association for Academic Surgery, California Medical Association, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

David A Piccoli, MD, Chief, Division of Gastroenterology and Nutrition, Department of Pediatrics, 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.

CME Editor

Steven M Schwarz, MD, FAAP, FACN, AGAF, Professor of Pediatrics, State University of New York, Downstate Medical Center College of Medicine; Distinguished Lecturer, New York Medical College, School of Public Health
Steven M Schwarz, MD, FAAP, FACN, AGAF is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, American Gastroenterological Association, American Pediatric Society, Gastroenterology Research Group, New York Academy of Medicine, North American Society for Pediatric Gastroenterology and Nutrition, and Society for Pediatric Research
Disclosure: TAP Pharmaceuticals Honoraria Speaking and teaching; Curemark, LLC Consulting fee Board membership

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.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
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.