eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology

Volvulus: Treatment & Medication

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

Treatment

Medical Care

Immediate surgical consultation is necessary in patients with volvulus.

  • Aggressive fluid resuscitation is indicated while awaiting surgical intervention.
  • Nasogastric decompression may be successful in alleviating vomiting and discomfort associated with obstruction.
  • Rectal tube decompression of the sigmoid volvulus can be achieved. This may be aided by endoscopic placement. 

Surgical Care

Do not delay operation in a patient who is not stable.

  • During operation, the midgut volvulus is reduced by untwisting the bowel in a counterclockwise fashion. Viability of the small bowel loops can then be assessed (see Media file 3).
  • Doppler probe or fluorescein with a Wood light may be helpful in documenting the viability of the bowel. Necrotic bowel is resected if it is encountered.
  • Most patients undergo the Ladd procedure (ie, appendectomy, division of mesenteric bands, and placement of the small intestine on the right and the colon on the left side of the abdomen). A laparoscopic Ladd procedure has been described with good success rates.3
  • Patients with questionable viability of a significant length of unresected bowel after the initial operation may require a second-look procedure 24 hours later to reevaluate the viability of the bowel.
  • Definitive treatment for sigmoid volvulus remains surgical with resection and primary anastomosis. As with most instances of bowel resection, an open approach is usually used.
  • Postoperatively, patients still require aggressive fluid resuscitation and intravenous (IV) antibiotics. IV parenteral nutrition is begun in patients that have undergone resection of a significant length of bowel.
  • When the entire bowel appears necrotic, massive resection typically results in short bowel syndrome and a lifetime of parenteral nutrition with its associated morbidities, most notably progressive cholestatic liver disease.
  • Small bowel transplant for short bowel syndrome continues to be associated with high morbidity and mortality, although increasing experience and advances in immunosuppressive therapy continue to increase the survival rates in children. Early listing with a small bowel transplant service before the development of end-stage liver disease may result in improved outcome after transplant.

Medication

Broad-spectrum antibiotics, such as ampicillin, clindamycin, and gentamicin or cefotetan, should be administered to the patients in whom vascular compromise, bowel necrosis, perforation, or sepsis is suspected. These agents have proven effective in decreasing the rate of postoperative wound infection and improving outcome.

Antibiotics

Empiric initial antimicrobial therapy must be comprehensive and should cover all likely pathogens in the clinical setting.


Ampicillin (Principen)

Interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms.

Adult

1-2 g/d PO divided q6h; 2-8 g/d IV/IM divided q4-6h

Pediatric

50 mg/kg/dose IV/IM q6h

Increased blood concentrations with probenecid; may decreased effectiveness of PO contraceptives

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose with renal failure; evaluate carefully to differentiate a nonallergic ampicillin rash from a hypersensitivity reaction


Gentamicin (Garamycin)

If used in combination with an antianaerobic agent, such as metronidazole, gentamicin provides broad gram-negative and anaerobic coverage. Dosing regimens are numerous and are adjusted based on creatinine clearance and changes in the volume of distribution.

Adult

2 mg/kg IV loading dose prior to surgery; then 3-5 mg/kg/d IV divided q8h

Pediatric

Infants/neonates: 7.5 mg/kg/d IV divided q8h
Children: 6-7.5 mg/kg/d IV divided q8h

Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; because aminoglycosides enhance effects of neuromuscular blocking agents prolonged respiratory depression may occur; coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)

Documented hypersensitivity; non–dialysis-dependent renal insufficiency

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Not for long-term therapy because of narrow therapeutic index and toxicity associated with extended administration; caution in patients diagnosed with renal failure (patient not on dialysis), hypocalcemia, myasthenia gravis, and conditions that depress neuromuscular transmission; adjust dose with renal impairment


Clindamycin (Cleocin)

Useful as a treatment against serious skin and soft tissue infections caused by most staphylococci strains. Is also effective against aerobic and anaerobic streptococci, except for enterococci. Inhibits bacterial protein synthesis by inhibiting peptide chain initiation at the bacterial ribosome, where it preferentially binds to the 50S ribosomal subunit, causing bacterial replication inhibition.

Adult

300-900 mg IV/IM q6-12h; not to exceed 4800 mg/d

Pediatric

Mild infection: 8-16 mg/kg/d IV/IM divided tid/qid
Serious infection: 16-20 mg/kg/d IV/IM divided tid/qid

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin

Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile


Cefotetan (Cefotan)

A second-generation cephalosporin used as single-drug therapy to provide broad gram-negative coverage and anaerobic coverage. The half-life is 3.5 h.

Adult

2 g IV prior to surgery, then 1-2 g IV/IM q12h for 5-10 d

Pediatric

20-40 mg/kg/dose IV/IM q12h for 5-10 d

Consumption of alcohol within 72 h of cefotetan may produce disulfiramlike reactions; cefotetan may increase hypoprothrombinemic effects of anticoagulants; coadministration with potent diuretics (eg, loop diuretics) or aminoglycosides may increase nephrotoxicity

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Reduce dosage by half for patients with creatinine clearance of 10-30 mL/min and by one fourth for patients with creatinine clearance <10 mL/min; use of antibiotics (especially prolonged or repeated therapy) may result in bacterial or fungal overgrowth of nonsusceptible organisms, possibly leading to secondary infection; take appropriate measures if superinfection occurs

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.