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Midgut Volvolus


Midgut volvulus


Important Definitions

Malrotation: Abnormal rotation & fixation of small bowel mesentery that can lead to complications

1.    Bowel obstruction by Ladd (peritoneal) bands

2.    Midgut volvulus (MV) due to short mesenteric base prone to twisting


Midgut volvulus: Abnormal twisting of small bowels about superior mesenteric artery (SMA) that can lead to bowel obstruction & bowel



Ligament of Treitz: Suspends duodenojejunal junction , defines normal duodenal rotation


Ladd band: Abnormal fibrous peritoneal bands that can cause duodenal obstruction


Bilious vomiting: Green/yellow vomit typically from obstruction of duodenum distal to ampulla of Vater



ü  Age

        within first 10 days of life (39%) .

        within first 3 months of life (90%)

        Can occur at any age

ü  Gender

        Slightly higher incidence in boys

ü  Epidemiology

        2.86/10,000 new births

        Incidence inversely proportional to maternal age


Clinical Features

  Classic presentation: Typically, the neonate is entirely normal for a period before suddenly presenting with bilious vomiting. If the volvulus does not spontaneously reduce, then the venous obstruction created by the superior mesenteric vein wrapped around the superior mesenteric artery results in venous obstruction and gradual onset of ischaemia and eventual necrosis. As this occurs, the abdomen becomes swollen as fluid accumulates in the lumen of the bowel, and becomes tender. Eventually, peritonitis and shock become established. Bilious vomiting in 1st month of life , However, can occur at any age, even in adulthood


  Other signs/symptoms

        Acute abdominal pain

        Vomiting, crampy abdominal pain

        Failure to thrive

        Patients may be asymptomatic or have atypical or chronic symptoms




        With normal rotation:Duodenojejunal junction positioned in left upper quadrant & cecum positioned in right lower quadrant. that Results in long fixed mesenteric base between ligament of Treitz & cecum that keeps mesentery from twisting


        If bowel malrotated: DJJ-cecal length (mesenteric base) is short, predisposing to twisting (volvulus) .

Nonrotation contribution controversial; may be most common form in patients with volvulus (if both DJJ & cecum in midline with short pedicle)

Isolated duodenal or colonic malrotation may also predispose to MV


        Rarely, Midgut Volvulus reported in setting of normal rotation; some of these cases may be segmental volvulus of ileum


Associations: may also be associated with duodenal obstruction from

        Ladd bands (abnormal fibrous peritoneal bands)

        Paraduodenal hernias



        diaphragmatic hernia

        duodenal or jejunal atresia





  Best diagnostic clue

        Upper GI showing mildly to moderately dilated duodenum (usually through D2-D3 segment) with corkscrew or spiral sign at or distal to beak of obstruction

        Whirlpool sign on US or CT: Wrapping of SB, its mesentery, & superior mesenteric vein (SMV) around SMA

        Usually associated with malrotated bowel, either duodenal or colonic or both



        Twisting of mesentery occurs about SMA, which can lead to venous obstruction, bowel wall ischemia, & necrosis

        Ladd bands may cause bowel obstruction, especially of duodenum



        Most common early finding: Normal abdominal radiograph

        Distended stomach & proximal duodenum with mild distal bowel gas very suggestive

        Not marked longstanding dilation without distal gas, as seen in duodenal atresia

        May show diffuse distal bowel distention/ileus from ischemia/necrosis . Such children often extremely ill

        Rarely pneumatosis, portal venous gas, free intraperitoneal air .


Fluoroscopic Findings

Upper GI

        Dilated duodenum to D2-D3, with "to-&-fro" motility due to obstruction . Degree of proximal duodenal dilation depends on chronicity

        Often beaked appearance at level of twist, ± complete obstruction

        Usually spiral/corkscrew appearance caudally, distal to beak

        May see malrotation without MV . In patients with bilious emesis, this may reflect intermittent volvulus


Contrast enema

        Colon often nonrotated with cecum in upper midline abdomen ± obstruction of ileocecal region


Ultrasonographic features

        Proximal duodenum usually dilated

        Whirlpool sign of swirling vessels (SMV) & small bowel mesentery around SMA in clockwise fashion on grayscale & color Doppler

        Small bowel may lack perfusion on color Doppler

        May see pneumatosis as foci of echogenicity with dirty shadowing within bowel wall circumferentially

        May see portal venous gas as punctate echogenic foci moving in portal vein(s) from liver hilum to periphery


CT Findings


        Whirlpool sign of swirling vessels (SMV) & SB mesentery around SMA

        Potentially or no enhancement of SB due to obstruction of SMA (due to ischemia/necrosis)

        May have SB distention due to ischemic ileus

        Pneumatosis, portal venous gas, & rarely free peritoneal air present


Best imaging tool

        Infant with bilious vomiting emergent upper GI

        Small bowel follow-through (SBFT) or contrast enema if no volvulus seen but malrotation suspected to document position of cecum

        Broadness of mesenteric base (DJJ-cecal distance) relates to potential risk of volvulus


Protocol advice

        In patients with high clinical suspicion of midgut volvulus Place nasogastric tube (if not already placed by clinicians)

        Aspirate as much fluid & air from stomach as possible prior to instilling contrast

        Inject 10 mL contrast into stomach in right lateral decubitus position

        If not emptying into duodenum, inject small amounts of air to encourage gastric emptying

        If volvulus seen, immediately notify referring clinicians

        Longer time interval from diagnosis to operation makes intestinal ischemia & bowel loss more likely

        Document duodenum in lateral & AP positions as per upper GI otherwise


Natural History & Prognosis & Treatment

Potential volvulus leading to bowel necrosis

Possible MV is one of few true emergencies in pediatric GI



Surgical emergency

Ladd procedure: Reduce volvulus, resect nonviable bowel, transect Ladd bands (if present), place SB in right & colon in left abdomen


Differential Diagnosis

1.    Malrotation With Obstructing Ladd (Peritoneal Fibrous) Bands

        May be completely obstructive with beaking, mimicking midgut volvulus .

        Cannot distinguish from midgut volvulus .fluoroscopically if corkscrew sign not seen

        US could distinguish by showing target/swirl sign of MV

        Must consider as tight MV & send for immediate surgical Treatment


2.    Spectrum of Congenital Duodenal Obstruction

        Duodenal atresia, duodenal stenosis, annular pancreas, duodenal web

        Atresia has double bubble sign, marked duodenal dilation with no distal gas; usually D1-D2 obstructed

        Stenosis or web usually has transition to normal distal duodenum & normal DJJ

        Can mimic MV fluoroscopically if corkscrew sign not Seen


3.    Redundant Duodenum

        Duodenum may make several retroperitoneal loops prior to extending leftward across spine to normal DJJ

        No duodenal dilation or obstruction




1. Carroll AG et al: Comparative effectiveness of imaging modalities for the diagnosis of intestinal obstruction in neonates and infants: a critically appraised topic. Acad Radiol. 23(5):559-68, 2016

2. Drewett M et al: The burden of excluding malrotation in term neonates with bile stained vomiting. Pediatr Surg Int. 32(5):483-6, 2016

3. Dumitriu DI et al: Ultrasound of the duodenum in children. Pediatr Radiol. 46(9):1324-31, 2016

4. Horsch S et al: Volvulus in term and preterm infants - clinical presentation and outcome. Acta Paediatr. 105(6):623-7, 2016

5. Shrimal PK et al: Midgut volvulus with whirlpool sign. Clin Gastroenterol Hepatol. 14(2):e13, 2016

6. Coe TM et al: Small bowel volvulus in the adult populace of the United States: results from a population-based study. Am J Surg. 210(2):201-210.e2, 2015

7. Kargl S et al: Volvulus without malposition--a single-center experience. J Surg Res. 193(1):295-9, 2015

8. Koong JK et al: Midgut volvulus: a rare cause of intestinal obstruction in adults. ANZ J Surg. ePub, 2015

9. Mitsunaga T et al: Risk factors for intestinal obstruction after Ladd procedure. Pediatr Rep. 7(2):5795, 2015

10. Shah MR et al: Volvulus of the entire small bowel w1th normal bowel fixation simulating malrotation and midgut volvulus. Pediatr Radiol. 45(13):1953-6, 2015

11. Marine MB et al: Imaging of malrotation in the neonate. Semin Ultrasound CT MR. 35(6):555-70, 2014

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