What is the appropriate management for a middle‑aged male with recurrent acute abdominal pain due to mid‑gut volvulus?

Management of Midgut Volvulus in a Middle-Aged Male with Recurrent Acute Abdominal Pain

Emergency surgical intervention with exploratory laparotomy is mandatory for midgut volvulus in adults, as this condition carries high risk of bowel ischemia and necrosis, and unlike sigmoid volvulus, endoscopic decompression has no role in management. 1, 2

Critical Distinction: Midgut vs. Sigmoid Volvulus

This is a midgut volvulus, not sigmoid volvulus, which fundamentally changes management:

• Midgut volvulus requires immediate surgery with no role for endoscopic intervention 1, 2
• Sigmoid volvulus (which affects elderly males with chronic constipation) can be managed with endoscopic decompression if uncomplicated 3, 4, 1
• The recurrent nature in a middle-aged male strongly suggests underlying intestinal malrotation, which predisposes to repeated volvulus episodes 2, 5

Diagnostic Workup

Obtain CT abdomen/pelvis immediately to confirm diagnosis and assess for bowel ischemia:

• Pathognomonic CT findings include: "whirlpool sign" (twisting of mesentery and vessels around superior mesenteric artery), "corkscrew sign," and abnormal SMA-SMV relationship with SMV positioned left of SMA 6, 7
• Plain radiographs show small bowel obstruction but are insufficient for definitive diagnosis 8
• Color Doppler ultrasound can demonstrate twisting of intestinal segments around SMA/SMV if CT unavailable 6

Surgical Management Algorithm

Proceed directly to emergency laparotomy without attempting endoscopic decompression:

• Intraoperative findings typically include: midgut volvulus (small bowel twisted around mesenteric root), intestinal malrotation with abnormal cecal position, possible adhesions, and occasionally associated pathology like jejunal diverticula 2, 5, 8
• Surgical steps: Detorsion of volvulus, assessment of bowel viability, lysis of adhesions, and correction of malrotation (Ladd's procedure) 2, 7
• If bowel necrosis present: Resect non-viable segments; limited right hemicolectomy may be required if terminal ileum/cecum involved 2
• Do not delay surgery as intestinal ischemia and necrosis develop rapidly, with associated high mortality 2, 6

Critical Management Pitfalls

The recurrent nature is the key warning sign:

• Recurrent volvulus can occur even years after initial Ladd's procedure for malrotation, making this a "dreadful" complication requiring high index of suspicion 2
• Each recurrence increases risk of ischemia, perforation, and mortality (similar principle to sigmoid volvulus) 1
• Intermittent colicky abdominal pain with asymptomatic intervals between episodes is characteristic of chronic/recurrent midgut volvulus 5

Common pitfall: Mistaking this for sigmoid volvulus based on "volvulus" terminology alone—sigmoid volvulus affects the large bowel in elderly patients and allows endoscopic management, while midgut volvulus affects small bowel and requires surgery 3, 1, 2

Postoperative Considerations

Definitive correction of malrotation during index operation is essential:

• Address underlying anatomic abnormality (malrotation) to prevent future recurrences 2, 7
• Resect any associated pathology (diverticula, strictures) identified intraoperatively 2, 5
• Most patients have excellent postoperative recovery when surgery performed before bowel necrosis develops 2, 7

Risk factors for poor outcomes include: age over 60 years, presence of shock on admission, and delayed presentation allowing bowel ischemia to develop 3, 2