Pediatrics · Year 3 · from Pediatrics
Case 3: Malrotation with Midgut Volvulus
Patient Demographics
- Age: 10-day-old male
- Sex: Male
Chief Complaint
"He's vomiting green stuff."
History of Present Illness
A 10-day-old male infant is brought to the emergency department after vomiting green (bilious) material three times over the past 4 hours. The baby was born at full term without complications and had been breastfeeding well until this morning. He fed normally at 6 AM but then had a large bilious vomit at 8 AM. He has continued to have bilious vomiting and now appears more irritable. He had a normal bowel movement yesterday. The parents have not noticed any blood in the vomit or stool. There is no fever. He was previously healthy with no prior hospitalizations.
Physical Examination
- Vital Signs: Temperature 37.0C, HR 175 bpm, RR 50/min, BP 62/40 mmHg
- General: Irritable, inconsolable infant
- Skin: Pale, mottled, capillary refill 3 seconds
- Abdomen:
- Mildly distended
- Tenderness to palpation diffusely
- No visible masses
- Hypoactive bowel sounds
- Rectal exam: Stool guaiac positive
Imaging Findings
- Abdominal X-ray: Dilated stomach with paucity of distal bowel gas (concerning but nonspecific)
- Upper GI series: Contrast shows duodenum crossing midline but terminating abruptly with "corkscrew" appearance; contrast does not progress normally
Diagnosis
Malrotation with midgut volvulus - SURGICAL EMERGENCY
Clinical Reasoning
BILIOUS VOMITING IN A NEONATE IS MALROTATION WITH VOLVULUS UNTIL PROVEN OTHERWISE. This is a true surgical emergency. Malrotation occurs when the intestine fails to complete normal rotation during fetal development, leaving the mesentery on a narrow stalk (Ladd's bands) that is susceptible to twisting (volvulus). When volvulus occurs, the entire midgut blood supply (superior mesenteric artery) is compromised. Without emergent intervention, the entire midgut will infarct within hours. The corkscrew appearance on UGI confirms the twisted, obstructed duodenum. Signs of shock (tachycardia, poor perfusion) and guaiac-positive stool suggest ischemia is already occurring.
Management
- EMERGENT SURGICAL CONSULTATION: Do not delay for additional workup
- NPO and NG tube: Decompress stomach
- IV fluid resuscitation: 20 mL/kg normal saline bolus; prepare for significant volume needs
- Type and screen: Prepare blood products for surgery
- Broad-spectrum antibiotics: Cover for potential bowel perforation and translocation
- Emergent laparotomy: Ladd procedure (counterclockwise detorsion, division of Ladd bands, widening mesentery, appendectomy, return bowel to abdomen with duodenum on right and cecum on left)
- Assess bowel viability: Surgeon will assess after detorsion; necrotic bowel may require resection
- Post-operative monitoring: Watch for short bowel syndrome if significant resection required
Key Teaching Point
"Bilious vomiting in a newborn is a surgical emergency until proven otherwise." While there are other causes of bilious vomiting, malrotation with volvulus is time-sensitive and must be excluded immediately. The consequences of missing this diagnosis (complete bowel necrosis) are catastrophic.
Clinical Image
Image Description: Upper gastrointestinal contrast study demonstrating the "corkscrew" or "bird's beak" appearance of the duodenum in malrotation with midgut volvulus, indicating obstruction of the twisted bowel.
Source: Radiopaedia URL: https://radiopaedia.org/cases/malrotation-with-midgut-volvulus License: CC BY-NC-SA 3.0