Volvulus (peds)

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%

Diagnosis

Clinical Presentation

• 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

Imaging

• Should not delay surgical consult
• AXR
  • 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 gass
  • 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
  • Highly sensitive and specific for volvulus
  • Usually not necessary in cecal volvulus
  • May be helpful in diagnosis of sigmoid volvulus, look for "whirl sign"

Differential Diagnosis

1. Duodenal stenosis/atresia
2. Bowel perforation
3. Sepsis

Pediatric Abdominal Pain

0–3 Months Old

• Emergent
  • Necrotizing Enterocolitis
  • Volvulus
  • Testicular torsion
  • Inguinal hernia
    • Incarcerated hernia
  • Trauma
  • Pyloric stenosis
  • Toxic megacolon
  • Hirschsprung's Disease
• Nonemergent
  • Constipation
  • Acute Gastroenteritis
  • Colic

3 mo–3 y old

• Emergent
  • Intussusception
  • Testicular Torsion
  • Trauma
  • Volvulus
  • Appendicitis
  • Toxic megacolon
  • Vaso-occlusive crisis
• Nonemergent
  • Acute Gastroenteritis
  • Constipation
  • Urinary tract infection
  • Henoch-Schonlein purpura

3 y old–adolescence

• Emergent
  • Appendicitis
  • DKA
  • Vaso-occlusive crisis
  • Toxic ingestion
  • Testicular Torsion
  • Ovarian Torsion
  • Ectopic Pregnancy
  • Trauma
  • Toxic megacolon
  • Inflammatory bowel disease
  • Gastric ulcer disease
  • Ovarian cyst
  • Pregnancy
  • Pancreatitis
  • Cholecystitis
  • Intussusception (to age 6)
• Nonemergent
  • Constipation
  • Acute Gastroenteritis
  • Nonspecific viral syndrome
  • Streptococcus pharyngitis
  • Urinary tract infection
  • Pneumonia
  • Renal Stone
  • Henoch-Schonlein purpura
  • Inflammatory bowel disease
  • Vulvovaginitis

Treatment

• NG tube decompression and laparotomy with Ladd procedure plus appendectomy
  • Immediate surgical consultation
• Aggressive 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

See Also

• Abdominal Pain (Peds)
• Volvulus (Adults)

Source

• Tintinalli
• Murphy MS. Management of bloody diarrhoea in children in primary care. BMJ. May 3 2008;336(7651):1010-5.
• Hostetler MA, Gastrointestinal Disorders, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. Philadelphia, PA, Saunders, 2014, (Ch) 172:p 2168-2187.