Volvulus (peds): Difference between revisions

No edit summary
No edit summary
 
(36 intermediate revisions by 12 users not shown)
Line 1: Line 1:
{{Peds top}} [[volvulus]].''
==Background==
==Background==
*Can occur at any time (though 50% of cases occur in 1st month of life)
*2 types: Sigmoid and cecal volvulus
*Surgical emergency
==Diagnosis==
*Can occur at any time
*S/S
**1st week of life: 33%  
**Sudden-onset, bilious vomiting (always consider a surgical emergency)
**1st month of life: 50%
abd pain & feeding intol in an otherwise healthy infant, bilious vomiting in 77-100% of cases. Volume depletion, grunting resps, jaundice (33%), shock, diffuse abd tenderness, bloody stools (late).* In '93 Torres etal found 22 pts undergoing surgery for malrotation 50% had nl abd exams and 32% had distension but no tenderness.
**1st year of life: 85%


* AXR* dilated stomach & duodenum w/o distal gas
==Clinical Features==
* can have nl xr.
*Classic Triad: [[Abdominal pain (peds)|abdominal pain]], increased abdominal distention, [[Constipation (peds)|constipation]]
* upper GI series shows narrowing at site of obstruction with corckscrewing around the SMA
*Alternative Presentation: bilious [[Nausea and vomiting (peds)|vomiting]], abdominal distension, tenderness, and a palpable mass
* Clockwise whirlpool sign using color doppler flow has a sensitivity 92%,spec 100%,PPV 100%
**Vomiting seen in 50% of cases
*[[Pediatric shock|Shock]] and [[peritonitis]] if perforated


==Differential Diagnosis==
{{Pediatric abdominal pain DDX}}
{{Constipation DDX}}


==DDx==
==Evaluation==
#Duodenal web
===Imaging===
#Duodenal stenosis
*Should not delay surgical consult
#Duodenal or ileal atresia
*[[KUB|Abdominal XR]]
#Ileus
**Sigmoid volvulus
***Classically see "coffee bean sign" - large, distended colon with gas that seems to be bent over itself, making coffee bean shape
==Treatment==
***Can also perform contrast enema, look for "bird beak" sign
*Supportive care w/ aggressive fluids, NGT, ABX (amp, gent, clinda)
***Frimann Dahl's sign
*Stable pt can have UGI series to confirm Dx
***Absent rectal gas
*shock pt needs surgery asap "time is bowel" (6 hr before bowel is dead)
**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"


==Source==
==Management==
Tintinalli
*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


[[Category:Peds]]
==Disposition==
*Admit
 
==See Also==
*[[Abdominal Pain (Peds)]]
*[[Volvulus (Adults)]]
 
==References==
<references/>
 
[[Category:Pediatrics]]
[[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

Retrieved from "https://www.wikem.org/w/index.php?title=Volvulus_(peds)&oldid=243065"