Volvulus (peds): Difference between revisions
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{{Peds top}} [[volvulus]].'' | |||
==Background== | ==Background== | ||
*2 types: Sigmoid and cecal volvulus | *2 types: Sigmoid and cecal volvulus | ||
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*Alternative Presentation: bilious [[Nausea and vomiting (peds)|vomiting]], abdominal distension, tenderness, and a palpable mass | *Alternative Presentation: bilious [[Nausea and vomiting (peds)|vomiting]], abdominal distension, tenderness, and a palpable mass | ||
**Vomiting seen in 50% of cases | **Vomiting seen in 50% of cases | ||
*[[Shock]] and [[peritonitis]] if perforated | *[[Pediatric shock|Shock]] and [[peritonitis]] if perforated | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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===Imaging=== | ===Imaging=== | ||
*Should not delay surgical consult | *Should not delay surgical consult | ||
*Abdominal XR | *[[KUB|Abdominal XR]] | ||
**Sigmoid volvulus | **Sigmoid volvulus | ||
***Classically see "coffee bean sign" - large, distended colon with gas that seems to be bent over itself, making coffee bean shape | ***Classically see "coffee bean sign" - large, distended colon with gas that seems to be bent over itself, making coffee bean shape | ||
***Can also perform contrast enema, look for "bird beak" sign | ***Can also perform contrast enema, look for "bird beak" sign | ||
***Frimann Dahl's sign | ***Frimann Dahl's sign | ||
***Absent rectal | ***Absent rectal gas | ||
**Cecal volvulus | **Cecal volvulus | ||
***May see findings similar to small bowel obstruction | ***May see findings similar to small bowel obstruction | ||
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==Management== | ==Management== | ||
*Emergent surgical consult | *Emergent surgical consult | ||
*Place NG tube | *Place [[NG tube]] | ||
*Fluid resuscitation | *[[Fluid resuscitation]] | ||
*Antibiotics if gangrenous bowel is suspected (triple coverage with ampicillin, gentamicin, metronidazole) | *[[Antibiotics]] if gangrenous bowel is suspected (triple coverage with ampicillin, gentamicin, metronidazole) | ||
*Sigmoid volvulus may be managed non-operatively by endoscopic detorsion | *Sigmoid volvulus may be managed non-operatively by endoscopic detorsion | ||
**Successful in 50-90% of cases | **Successful in 50-90% of cases | ||
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[[Category:Pediatrics]] | [[Category:Pediatrics]] | ||
[[Category:GI]] | [[Category:GI]] | ||
[[Category:Surgery]] | |||
Latest revision as of 19:15, 23 January 2020
This page is for pediatric patients. For adult patients, see: volvulus.
Background
- 2 types: Sigmoid and cecal volvulus
- Surgical emergency
- Can occur at any time
- 1st week of life: 33%
- 1st month of life: 50%
- 1st year of life: 85%
Clinical Features
- Classic Triad: abdominal pain, increased abdominal distention, constipation
- Alternative Presentation: bilious vomiting, abdominal distension, tenderness, and a palpable mass
- Vomiting seen in 50% of cases
- Shock and peritonitis if perforated
Differential Diagnosis
Pediatric Abdominal Pain
0–3 Months Old
- Emergent
- Nonemergent
3 mo–3 y old
- Emergent
- Nonemergent
3 y old–adolescence
- Emergent
- Nonemergent
Constipation
- Behavioral-related
- Lack of exercise
- Diet-related
- Fecal impaction
- Ileus from surgical abdomen
- Bowel obstruction
- Small bowel obstruction
- Large bowel obstruction
- Malignant bowel obstruction
- Specific causes: tumor, stricture, hernia, adhesion, volvulus
- Painful anorectal disorders (e.g. anal fissure, hemorrhoids)
- Medical causes
- Hypothyroidism
- Electrolytes
- Hypokalemia
- Medication-related
- Opiods, antipsychotics, anticholinergics, antacid, antihistamines
- Constipation (peds)
Evaluation
Imaging
- Should not delay surgical consult
- Abdominal XR
- Sigmoid volvulus
- Classically see "coffee bean sign" - large, distended colon with gas that seems to be bent over itself, making coffee bean shape
- Can also perform contrast enema, look for "bird beak" sign
- Frimann Dahl's sign
- Absent rectal gas
- Cecal volvulus
- May see findings similar to small bowel obstruction
- Air-fluid level, paucity of gas
- Distended loop of colon with haustral markings
- May see findings similar to small bowel obstruction
- Malrotation with midgut volvulus
- Upper GI with contrast
- Obstructed duodenum with corkscrew appearance
- Misplaced duodenum as demonstrated by NG tube
- May see double-bubble sign due to obstruction
- US may show SMA compromise
- Upper GI with contrast
- Sigmoid volvulus
- CT Abd/pelvis
- Highly sensitive and specific for volvulus
- Usually not necessary in cecal volvulus
- May be helpful in diagnosis of sigmoid volvulus, look for "whirl sign"
Management
- Emergent surgical consult
- Place NG tube
- Fluid resuscitation
- Antibiotics if gangrenous bowel is suspected (triple coverage with ampicillin, gentamicin, metronidazole)
- Sigmoid volvulus may be managed non-operatively by endoscopic detorsion
- Successful in 50-90% of cases
- Contraindicated if perforation or gangrenous bowel suspected
- All cases of cecal volvulus should be managed operatively
Disposition
- Admit