What is the management for midgut volvulus with bilious vomiting in a 5-month-old patient?

Management of Midgut Volvulus with Bilious Vomiting in a 5-Month-Old

Midgut volvulus with bilious vomiting in a 5-month-old infant requires immediate surgical intervention—this is a life-threatening emergency where delays can result in catastrophic bowel necrosis and death. 1, 2

Immediate Clinical Actions

Resuscitation and Stabilization

• Place the infant NPO (nothing by mouth) immediately and insert a nasogastric tube for gastric decompression 2
• Establish IV access and begin aggressive fluid resuscitation with isotonic crystalloids to correct dehydration and electrolyte abnormalities 2
• Obtain urgent pediatric surgical consultation—do not delay surgery for extensive imaging workup if clinical suspicion is high 2, 3
• Monitor for signs of shock, peritonitis, or hemodynamic instability that indicate bowel ischemia 2

Diagnostic Approach

Initial Imaging

• Obtain plain abdominal radiographs first, though normal films do not exclude malrotation or volvulus 1
• Look for signs of proximal bowel obstruction, abnormal gas patterns, or pneumatosis intestinalis suggesting ischemia 1

Confirmatory Imaging (if patient is stable)

• Upper GI series is the reference standard for diagnosing malrotation and volvulus, showing abnormal position of the duodenojejunal junction (ligament of Treitz) 1
• The UGI has 96% sensitivity but can have false-positives (10-15%) and false-negatives due to redundant duodenum or bowel distension 1
• Ultrasound with color Doppler can identify the "whirlpool sign" (clockwise wrapping of the superior mesenteric vein and mesentery around the superior mesenteric artery), which is highly specific for midgut volvulus 1, 4
• The whirlpool sign on ultrasound can substantiate diagnosis when UGI is equivocal or help achieve rapid diagnosis 1, 4

Surgical Management

Operative Intervention

• Proceed urgently to laparotomy or laparoscopy for Ladd procedure, which involves: 2, 4

  • Detorsion of the volvulus (counterclockwise rotation)
  • Division of Ladd bands
  • Widening of the mesenteric base
  • Appendectomy
  • Placement of bowel in non-rotated position (duodenum on right, colon on left)

• Assess bowel viability intraoperatively—viable bowel should be preserved; necrotic segments require resection 4

• Early surgical intervention (within hours, not days) prevents intestinal ischemic changes and improves outcomes 4

Critical Pitfalls to Avoid

• Do not wait for definitive imaging if the patient is unstable—clinical presentation of bilious vomiting in an infant warrants immediate surgical exploration if volvulus is suspected 2, 3
• Do not be falsely reassured by normal abdominal examination—patients with midgut volvulus often have minimal physical findings early in the course 2
• Do not delay surgery for contrast enema—this has no role in diagnosing or managing midgut volvulus 1
• Recognize that bloody stools or melena indicate advanced ischemia and require even more urgent intervention 2, 4

Prognosis

• When diagnosed and treated early (before bowel necrosis), outcomes are excellent with full recovery expected within 2-3 weeks 4
• Delayed diagnosis leading to extensive bowel necrosis can result in short-gut syndrome, requiring long-term parenteral nutrition, or death 2, 3
• The key determinant of outcome is time from symptom onset to surgical detorsion 2, 4, 3