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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**1st year of life: 85%
**1st year of life: 85%


==Diagnosis==
==Clinical Features==
===Clinical Presentation===
*Classic Triad: [[Abdominal pain (peds)|abdominal pain]], increased abdominal distention, [[Constipation (peds)|constipation]]
*Classic Triad: abdominal pain, increased abdominal distention, constipation
*Alternative Presentation: bilious [[Nausea and vomiting (peds)|vomiting]], abdominal distension, tenderness, and a palpable mass
*Alternative Presentation: bilious 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==
{{Pediatric abdominal pain DDX}}
{{Constipation DDX}}
==Evaluation==
===Imaging===
===Imaging===
*Should not delay surgical consult
*Should not delay surgical consult
*AXR
*[[KUB|Abdominal XR]]
**Sigmoid volvulus
**Sigmoid volvulus
***Distended loop of colon without haustral markings
***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
**Cecal volvulus
***May see findings similar to small bowel obstruction
***May see findings similar to small bowel obstruction
****Air-fluid level, paucity of gas
****Air-fluid level, paucity of gas
***Classically see "coffee bean sign", large, distended colon with gas that seems to be bent over itself, making coffee bean shape
***Distended loop of colon with haustral markings
***Can also perform contrast enema, look for "bird beak" sign
**Malrotation with midgut volvulus
*CT
***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
*CT Abd/pelvis
**Highly sensitive and specific for volvulus
**Highly sensitive and specific for volvulus
**Usually not necessary in cecal volvulus
**Usually not necessary in cecal volvulus
**May be helpful in diagnosis of sigmoid volvulus, look for "whirl sign"
**May be helpful in diagnosis of sigmoid volvulus, look for "whirl sign"


==DDx==
==Management==
#Intussusception
*Emergent surgical consult
#Duodenal stenosis/atresia
*Place [[NG tube]]
#Bowel perforation
*[[Fluid resuscitation]]
#Sepsis
*[[Antibiotics]] if gangrenous bowel is suspected (triple coverage with ampicillin, gentamicin, metronidazole)
==Treatment==
*NG tube decompression and laparotomy
**Immediate surgical consultation
*Aggressive resuscitation
*Antibiotics if gangrenous bowel is suspected
*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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*All cases of cecal volvulus should be managed operatively
*All cases of cecal volvulus should be managed operatively


== See Also ==
==Disposition==
*Admit
 
==See Also==
*[[Abdominal Pain (Peds)]]  
*[[Abdominal Pain (Peds)]]  
*[[Volvulus (Adults)]]
*[[Volvulus (Adults)]]


==Source==
==References==
Tintinalli
<references/>


[[Category:Peds]]
[[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

Differential Diagnosis

Pediatric Abdominal Pain

0–3 Months Old

3 mo–3 y old

3 y old–adolescence

Constipation

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
    • 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
  • 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

See Also

References

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