What is the diagnostic and treatment approach for suspected volvulus in pediatric patients?

Diagnosis and Management of Volvulus in Pediatric Patients

Critical Distinction: Pediatric vs Adult Volvulus

In pediatric patients, volvulus most commonly involves midgut volvulus associated with malrotation (not sigmoid volvulus), and represents a true surgical emergency requiring immediate intervention to prevent bowel ischemia, necrosis, and death. 1

Clinical Presentation

Midgut Volvulus (Most Common in Pediatrics)

• Bilious emesis in infants is the hallmark symptom and should trigger immediate evaluation for malrotation with volvulus 1
• Patients may present with hemodynamic compromise and peritonitis if necrosis and perforation have occurred 1
• Symptom acuity varies based on the gastrointestinal segment affected, degree of twisting, and timing of presentation 1

Gastric Volvulus (Less Common)

• Presents with retching with or without nonbilious emesis, epigastric distension, and pain 1
• Median age of presentation is 24 months, with vomiting being the most common symptom 2
• Acute presentation occurs in the majority of cases and is associated with mesenteroaxial type and ischemia 2
• Chronic presentation includes recurrent postprandial vomiting with failure to thrive 3

Diagnostic Approach

First-Line Imaging

• Ultrasound is increasingly used as first-line imaging for midgut malrotation and volvulus, though upper GI series has historically been preferred 4
• Plain radiography can identify signs of obstruction or perforation 1
• Upper GI series remains the gold standard for definitive diagnosis when ultrasound is equivocal 4

For Gastric Volvulus

• Barium study allows definitive diagnosis of chronic organoaxial gastric volvulus 3
• Radiology is diagnostic in most cases of gastric volvulus 2

Critical Pitfall

• High clinical suspicion is essential as related symptoms are nonspecific and can mimic other conditions 3, 1
• Early diagnosis is crucial to prevent life-threatening complications including intestinal ischemia, infarction, strangulation, necrosis, and perforation 3

Treatment Algorithm

Immediate Actions

1. Emergent consultation with pediatric surgery specialist is mandatory when volvulus is suspected 1
2. If pediatric surgery is unavailable, immediate transfer to a center with pediatric surgical capability is required 1
3. Initiate resuscitation and administer antibiotics 1

Definitive Management

For Midgut Volvulus

• Emergent surgical decompression and detorsion of involved segments is required 1
• This is a surgical emergency with no role for conservative management when midgut volvulus is confirmed 1

For Gastric Volvulus

• Surgical management is preferred in the majority of cases, typically including gastropexy, gastrostomy, or gastric resection 2
• Variations of gastropexy are the preferred surgical approach 2
• Nonoperative approach is advisable only in the absence of warning signs (no ischemia, perforation, or hemodynamic compromise) 3
• Endoscopic management has been reported but carries risk of recurrence 2

Outcomes and Complications

Mortality and Morbidity

• Mortality is considerable at 6.4% in gastric volvulus cases 2
• Morbidity and mortality from colonic volvulus are high, emphasizing need for expedient diagnosis 5
• Complications occur in 18.9% of gastric volvulus cases, with esophageal stenosis being most common 2

Recurrence

• Only one recurrence reported after endoscopic management in pediatric gastric volvulus series 2
• Median follow-up period is 12 months 2

Key Differences from Adult Sigmoid Volvulus

Note: The provided guidelines 6, 7, 8 primarily address sigmoid volvulus in adults, which is a different entity than pediatric volvulus. In adults, sigmoid volvulus can be managed with endoscopic decompression initially, but this approach does not apply to pediatric midgut volvulus, which requires immediate surgery 1.