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Volvulus and intestinal malrotation

Last updated: December 8, 2020

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Volvulus is defined as the twisting of a loop of bowel on its mesentery and is one of the most common causes of intestinal obstruction. The sigmoid colon, and less frequently, the cecum, are the common sites of volvulus in adults. Volvulus in a neonate or infant almost always presents as a midgut volvulus secondary to intestinal malrotation. Patients typically show features of bowel obstruction (abdominal pain, distension, bilious vomiting) or of bowel ischemia and gangrene (tachycardia, hypotension, hematochezia, peritonitis) in severe cases. The whirl sign and a grossly dilated loop of bowel on an abdominal CT scan establish the diagnosis of volvulus in adults. Upper GI series is the investigation of choice in infants with suspected midgut volvulus, which is seen as a cork-screw duodenum. Sigmoid volvulus without peritonitis is initially managed with endoscopic detorsion, followed by a semi-elective surgery (sigmoid colectomy). Sigmoid volvulus with peritonitis, and all cases of cecal volvulus, require emergency surgery. Endoscopic detorsion should not be attempted in a patient with cecal volvulus because of the high risk of perforation. The Ladd procedure (laparotomy and detorsion of the volvulus) is indicated in all patients with intestinal malrotation since it is impossible to predict if volvulus of the midgut will occur in an asymptomatic patient or not.

SigmOid volvulus is more common in Older individuals while Midgut volvulus and Malrotation are more common in Minors.

Epidemiological data refers to the US, unless otherwise specified.

Clinical features

Differential diagnoses

Treatment [6][7]

  • Initial resuscitation: IV fluids; acid-base and electrolyte imbalance correction; NPO; placement of a nasogastric tube
  • Evaluation
  • Surgery

References:[3][6][7][8][9][10][11]

Types [12]

Clinical features

  • Acute presentation: features of small bowel obstruction
  • Insidious onset: recurrent episodes of right lower abdominal pain

Differential diagnoses

Treatment [10]

  • Initial resuscitation (See “Treatment” of sigmoid volvulus above.)
  • Surgery

Definition

Common types of intestinal malrotation [6][14][15]
Nonrotation Incomplete rotation
  • The mesenteric attachment has a wider base than in incomplete rotation

Clinical presentation

Differential diagnoses [17][18]

Treatment

References:[14][15][18][19][20]

Volvulus

Intestinal malrotation and midgut volvulus

Imaging in intestinal malrotation and midgut volvulus

Intestinal malrotation

Midgut volvulus

Upper GI series (gold standard in hemodynamically stable patients) [15][25]

  • Displaced duodenojejunal junction
  • The small bowel is right-sided.
Barium enema (lower GI series)
Abdominal ultrasound [26]

CECT scan (oral and IV contrast)

Abdominal x-ray

References:[15][21][22][23][24][25][26][27][28]

See “Differential diagnosis of lower gastrointestinal bleeding in children.”

The differential diagnoses listed here are not exhaustive.

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