Volvulus (Children)

🍼 In children, volvulus is often a life-threatening surgical emergency. 🚨 It usually arises from malrotation of the midgut rather than a redundant sigmoid colon. ⏱️ Rapid recognition and urgent surgery are critical to prevent ischaemia and necrosis.

📖 About

• ⚠️ Midgut volvulus is the most serious complication of intestinal malrotation.
• Occurs when the small intestine twists around the superior mesenteric artery (SMA), compromising both blood flow and bowel lumen.
• Most cases present in neonates and infants, but can occur at any age.

🧬 Aetiology & Pathophysiology

• 🔄 Failure of normal 270° counter-clockwise rotation of the midgut in utero.
• Leads to a narrow mesenteric base, predisposing to torsion around the SMA.
• 🔌 Consequence: acute bowel obstruction + ischaemia → rapid progression to necrosis.
• Unlike adults, sigmoid or caecal volvulus is rare in children outside of chronic conditions (e.g., Hirschsprung’s, neurodevelopmental delay).

🤝 Associations

• 👶 Neonates - most common age of presentation.
• Congenital anomalies: malrotation, diaphragmatic hernia, heterotaxy.
• Underlying conditions: Hirschsprung’s disease, chronic constipation, intestinal pseudo-obstruction.

🩺 Clinical Presentation

• 💚 Sudden onset bilious (green) vomiting - classic red flag in neonates/infants.
• 😖 Severe abdominal pain, irritability.
• 🤢 Abdominal distension ± peritonitis if perforated.
• ⚡ Rapid cardiovascular collapse if ischaemia develops.

🔍 Investigations

• 📸 Plain AXR: May show double-bubble or gasless abdomen, but can be non-specific.
• 🖥️ Upper GI contrast study: Gold standard - abnormal position of duodenojejunal flexure, “corkscrew sign.”
• 🔬 Ultrasound: Can show "whirlpool sign" of twisted mesenteric vessels around SMA.
• ⚠️ Do not delay surgery if clinical suspicion is high.

⚕️ Management

• Initial: ABC resuscitation, IV fluids, broad-spectrum antibiotics, NG tube decompression.
• Surgical: 🚨 Ladd’s procedure is the operation of choice: - Untwist the volvulus (counter-clockwise). - Divide Ladd’s bands (peritoneal attachments causing duodenal obstruction). - Broaden mesenteric base to reduce recurrence risk. - Appendicectomy often performed (appendix in abnormal position can confuse future diagnosis).
• ❌ If bowel is necrotic → resection ± stoma formation, with risk of short bowel syndrome.

📚 References

• APSAPS (Association of Paediatric Surgeons of Great Britain & Ireland) guidelines on malrotation and volvulus.
• Nelson Textbook of Paediatrics - Intestinal Obstruction.

🌀 Case 1 - Midgut Volvulus in an Infant

A 3-week-old boy presents with sudden onset of bilious vomiting, abdominal distension, and irritability. On examination, he is tachycardic, with a tender, distended abdomen and poor perfusion. 💡 Midgut volvulus in infants usually arises from congenital malrotation, where abnormal embryological rotation leaves the bowel prone to twisting around the superior mesenteric artery. This can rapidly cause ischaemia and necrosis. It is a surgical emergency requiring urgent laparotomy (Ladd’s procedure) to untwist and prevent bowel loss.