Signs and Symptoms
History
- Infants: Vomiting in 90%:
- Older children and adults: Variable and often insidious:
- 80% with chronic symptoms; weeks to months to years
- Bowel obstruction secondary to volvulus:
- Colicky, cramping abdominal pain (90%)
- Abdominal distention (80%)
- Obstipation (60%)
- Nausea and vomiting (28%)
- Cecal volvulus:
- Highly variable; intermittent episodes to sudden onset of pain and distention
- Sigmoid volvulus:
- Vomiting uncommon
- More insidious onset
- Abdominal pain/distention, nausea, and constipation
- Gastric volvulus:
- Triad of Borchardt: Severe epigastric distension, intractable retching, inability to pass nasogastric tube (30% of patients)
Physical Exam
- Presence of gangrenous bowel:
- Increased pain
- Peritoneal signs: Guarding, rebound, and rigidity
- Fever
- Blood on digital rectal exam
- Tachycardia and hypovolemia
- Cecal volvulus:
- Distended abdomen
- Often a palpable mass in the left upper quadrant/midabdomen
Pediatric Considerations |
- Child will appear well with normal exam early in clinical course
- 70% present with chronic symptoms
- 40% of neonates with bilious vomiting will require a surgical intervention
- Hematochezia, abdominal distention or pain, and shock indicate ischemia/necrosis
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Essential Workup
- CBC, BMP, UA
- Plain abdominal radiograph
- Upper GI series (best initial exam for children)
- CT abdomen/pelvis with IV contrast (optimal for adults)
- Barium enema
- US
Diagnostic Tests & Interpretation
Lab
- May give clues as to the presence of gangrenous bowel, but normal lab values do not exclude the diagnosis
- CBC:
- Leukocytosis (WBC >20,000) suggests strangulation with infection/peritonitis
- Electrolytes, BUN, creatinine, glucose:
- Anion gap acidosis due to lactic acidosis
- Prerenal azotemia due to dehydration
- Urinalysis:
- Elevated specific gravity and ketones
Imaging
- Plain abdominal radiograph:
- Suggestive but often inconclusive
- Diagnostic finding present in <70% of cases
- Sigmoid volvulus: Inverted U-shaped loop of dilated colon arising from the pelvis
- Cecal volvulus - dilated and displaced:
- Cecum in the left abdomen (kidney shaped), often with dilated loops of small bowel
- CT scan:
- “Whirl” sign in cecal volvulus
- May be useful in sigmoid volvulus to determine extent of obstruction
- Upper GI series (best for duodenum, but operator dependent):
- Abrupt ending or corkscrew tapering of contrast seen (75%)
- Subtle findings (25%)
- Barium enema:
- “Bird's beak” deformity at the site of torsion
- Perform cautiously because of perforation risk
- Beware of false positives with infants who normally have inadequately fixed cecums
- US (specific but not sensitive):
- Abnormal position of the superior mesenteric vein (anterior or left of SMA)
- “Whirlpool” sign of volvulus: Vessels twirled around the base of the mesentery
- Third part of duodenum not in normal retromesenteric position (between mesenteric artery and aorta)
Pediatric Considerations |
- Diagnosis of midgut volvulus:
- Duodenum lies entirely to the right of the spine on plain films
- “Double-bubble” sign on an upright film due to distended stomach and proximal duodenal loop
- Established by upper GI swallow: Coiled spring/corkscrew appearance of jejunum in the right upper quadrant
- Plain x-ray normal or equivocal in 20% of cases
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ALERT |
- Evaluate any child with signs/symptoms of obstruction (including bilious vomiting and abdominal pain) for malrotation, even if he or she appears nontoxic
- Delay in diagnosis >1-2 hr results in gangrenous bowel, necessitating large resection and leading to permanent parenteral nutrition with its associated complications
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Diagnostic Procedures/Surgery
- Laparoscopy:
- Useful when diagnostic imagining equivocal
- Can differentiate congenital malrotation from volvulus
Differential Diagnosis
- Obstruction due to colonic tumor or diverticulitis
- Small bowel obstruction
- Ileus
- Intussusception
- Appendicitis
- Pelvic inflammatory disease and salpingitis, especially for cecal volvuli
- Ovarian torsion
- Perforated viscus
- Cyclic vomiting syndrome
Pediatric Considerations |
- Meconium ileus
- Hirschsprung disease
- Duodenal atresia
- Meckel diverticulum
- Necrotizing enterocolitis (especially premature infants)
- Intussusception
- Appendicitis
- Medical conditions:
- Colic
- Henoch-Schönlein purpura
- Inborn errors of metabolism
- Trauma
- Gastroesophageal reflux
- Pyelonephritis
- Meningitis
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Prehospital
Initial Stabilization/Therapy
- ABCs
- Aggressive fluid resuscitation with 0.9% NS bolus of 20 mL/kg (peds) or 2-L bolus (adult)
- NGT
ED Treatment/Procedures
- Obtain surgical and /or GI consultation
- NPO
- Correct hypovolemia and electrolyte abnormalities
- Preoperative broad-spectrum antibiotics if suspected sepsis or perforation
Definitive Therapy
Sigmoid Volvulus
- Nontoxic patient:
- Reduce volvulus nonoperatively with sigmoidoscopy:
- 80-95% successful
- 60% recurrence (within hours to weeks)
- Follow with elective sigmoid resection and primary anastomosis (<3% recurrence)
- Toxic patient:
- Emergent resection of sigmoid and any gangrenous bowel, with placement of end colostomy
- Endoscopic decompression with rectal tube placement:
- Successful in 78% of patients with sigmoid volvulus; less effective for cecal volvulus
- Recurrence is common
- Elective surgical treatment after endoscopic detorsion
Cecal Volvulus
Emergent operative reduction followed by colectomy and primary anastomosis (preferred), or cecopexy if the cecum is still viable (higher recurrence)
Pediatric Considerations |
- Laparotomy within 1-2 hr to reduce risk for ischemia
- Surgical detorsion of bowel with resection of gangrenous bowel and a Ladd procedure is performed to prevent recurrent volvulus
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Medication
- Ampicillinsulbactam (Unasyn): 3 g (peds: 100-200 mg/kg/24 hr) IV q6h
- Cefoxitin (Mefoxin): 2 g (peds: 80-160 mg/kg/24 hr) IV q6h
- Ceftriaxone 1-2 g IV q12-24h (peds: 50-75 mg/kg/d q12-24h) and metronidazole 500 mg IV q8h (peds: 30 mg/kg/24 hr q6h)
- Piperacillin-tazobactam 3.375-4 g IV q4-6h (peds: 200-300 mg/kg/d of piperacillin component q6-8h)
Disposition
Admission Criteria
Admit with a surgical consult all suspected of having a volvulus
Issues for Referral
- Surgical consultation necessary
- Atypical malrotation: Asymptomatic or symptoms of gastroesophageal reflux:
- Close observation with repeat contrast study
- Defer surgery
Follow-up Recommendations
Surgical follow-up postoperatively
- KapadiaM. Volvulus of the small bowel and colon . Clin Colon Rectal Surg. 2017;30(1):40-45.
- MorrisG, Kennedy Jr A , CochranW. Small bowel congenital anomalies: A review and update . Curr Gastroenterol Rep. 2016;18(4):16.
- PerrotL, FohlenA, AlvesA, et al. Management of the colonic volvulus in 2016 . J Visc Surg. 2016;153(3):183-192.
- SawaiRS. Management of colonic obstruction: A review . Clin Colon Rectal Surg. 2012;25(4):200-203.
- VogelJD, FeingoldDL, StewartDB, et al. Clinical practice guidelines for colon volvulus and acute colonic pseudo-obstruction . Dis Colon Rectum. 2016;59:589-600.
See Also (Topic, Algorithm, Electronic Media Element)
Bowel Obstruction