History and exam
Key diagnostic factors
common
bilious vomiting
Green vomit is often of sudden onset and vomiting of some form is present in >90% of cases of midgut volvulus.
abdominal pain
Pain is usually severe with an onset so sudden the parents may recall the exact time it started. As many of the patients are infants, the pain manifests as a notable transition to an inconsolable state.
Other diagnostic factors
common
infant age <1 year
Of patients with malrotation who become symptomatic, 50% to 75% do so in the first month and about 90% within the first year of life.[6]
normal abdominal exam
A distended abdomen is more commonly a bowel obstruction further downstream. Vomiting and abdominal pain with a flat abdomen should alert physicians to the presence of volvulus.
abdominal distension
Progressive distension usually follows bowel ischemia and swelling, which foreshadows a poor outcome.
abdominal tenderness
May be a presenting feature of obstruction with ischemia (midgut volvulus with vascular compromise).
tachycardia with hypertension
Initially the severe abdominal pain causes tachycardia with hypertension. An elevated heart rate from pain and bowel ischemia may reach >200 bpm in an infant, which should precipitate an early surgical consult.
tachycardia with hypotension
If ischemia exists, the toxic products of tissue infarction create a picture of early systemic inflammatory response syndrome. The resultant loss of endothelial integrity creates loss of intravascular volume and tone, causing severe hypotension and tachycardia.
uncommon
tachypnea
In the physiologic response to acidosis, the patient may be breathing quickly and if the abdomen is becoming tender from infarction, the breaths are shallow and short.
weight loss
May be a feature of intermittent or partial volvulus or obstructing Ladd bands.
dark blood in diaper
Caregiver may notice this.
rebound tenderness and guarding
Peritoneal signs may occur with midgut volvulus.
Risk factors
strong
embryologic abnormality
Rotation may be arrested at any point in midgut development creating the myriad conditions described by the term malrotation.
Furthermore, other embryologic abnormalities that disrupt the intestinal rotation and fixation process may lead to the development of various forms of malrotation.[7] These include abdominal wall defects (i.e., gastroschisis, omphalocele); congenital diaphragmatic hernia; or heterotaxy syndromes.
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