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AUTHOR AND EDITOR INFORMATION

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Author: Jonathan E Markowitz, MD, Associate Professor of Clinical Pediatrics, University of South Carolina School of Medicine; Attending Pediatric Gastroenterologist, Associate Director of Pediatric Residency Program, Greenville Hospital System

Jonathan E Markowitz is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, Crohns and Colitis Foundation of America, and North American Society for Pediatric Gastroenterology and Nutrition

Coauthor(s): Liz D Dancel, MD, Intern, Department of Pediatrics, Greenville Hospital System University Medical Center; Prem C Shukla, MD, Associate Chairman, Associate Professor, Department of Emergency Medicine, University of Arkansas for Medical Sciences

Editors: Jeffrey J DuBois, MD, Consulting Staff, Division of Pediatric Surgery, Kaiser Permanente, North Sacramento Medical Center; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; David A Piccoli, MD, Chief, Division of Gastroenterology and Nutrition, Department of Pediatrics, The Children's Hospital of Philadelphia; Professor, University of Pennsylvania School of Medicine; Steven M Schwarz, MD, FAAP, FACN, AGAF, Professor of Pediatrics, State University of New York, Downstate Medical Center College of Medicine; Distinguished Lecturer, New York Medical College, School of Public Health; Carmen Cuffari, MD, Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine

Author and Editor Disclosure

Synonyms and related keywords: midgut volvulus, intestinal malrotation, superior mesenteric artery, SMA, midgut, rotational abnormality, extracoelomic elongation, duodenal loop, cecocolic loop, Ladd bands, sigmoid volvulus, duodenal atresia, Meckel diverticulum, intussusception, small bowel atresia, prune belly syndrome, gastric volvulus, persistent cloaca, Hirschsprung disease, extrahepatic biliary anomalies, Chagas disease, feeding intolerance, failure to thrive, constipation, bloody diarrhea, hematemesis, irritable bowel syndrome, peptic ulcer disease, kidney stones, peritonitis, hematochezia, ischemia, gangrene, intestinal ischemia, necrosis, abdominal distension, hypovolemia, septic shock

INTRODUCTION

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Background

Volvulus is defined as a complete twisting of a loop of intestine around its mesenteric attachment site. Such twisting can occur at various sites of the GI tract, including the stomach, small intestine, cecum, transverse colon,1 and sigmoid colon. Midgut volvulus refers to twisting of the entire midgut around the axis of the superior mesenteric artery. This article mainly concerns midgut volvulus because it is the most common type of volvulus and is very serious in infants and children. Sigmoid volvulus is also briefly discussed below.

Numerous rotational abnormalities have been described that correlate with abnormal embryologic development of the midgut. Mall first described intestinal rotation during the embryologic period in 1898. However, Waugh in 1911 first described the clinical presentation of intestinal malrotation. Ladd, reporting in 1936, wrote the classic paper on surgical treatment of malrotation.

Pathophysiology

Embryologically, extracoelomic development with rapid elongation of the fetal intestine occurs at 4-8 weeks' gestation. The superior mesenteric artery (SMA), which supplies the small intestine and proximal colon, acts as the main supply of blood to these segments and acts as the axis of their subsequent rotation.

After extracoelomic elongation has occurred, the duodenal loop begins its counterclockwise 270° rotation around the SMA while returning to the abdomen; the loop initially passes to the right of the SMA, then passes below it, and, finally, passes to the left it, where the loop becomes fixed. The loop forms the ligament of Treitz and forms the normal duodenal C-shaped extension toward the left side across the midline. At the same time, the cecocolic loop begins its rotation below the SMA, rotating first to the left, then above, and, finally, to the right of the SMA. At this stage, the cecum descends from the right upper quadrant to the right lower quadrant.

If the duodenal loop remains on the right side of the abdomen, and the cecocolic loop remains on the left in relation to the SMA, nonrotation is the result. On the other hand, malrotation results from an interruption in intestinal rotation during the second stage of development. In malrotation, the duodenal loop lacks 90° of its normal 270° rotation, and the cecocolic loop lacks 180° of its normal rotation.

Malrotation leaves the cecum high in the mid abdomen with its peritoneal attachments, called the Ladd bands. These bands stretch from the cecum to the right lateral abdominal wall, causing compression of the duodenum and mechanical obstruction. Abnormal fixation of the ligament of Treitz causes narrowing and kinking of the duodenum near its junction with the jejunum. Along with it, the mesentery remains bunched up in the epigastrium and does not fan out.

All these anatomic factors cause the small bowel and its vascular supply to become suspended from a narrow pedicle, like a bell clapper, which predisposes to midgut volvulus and infarction.

Displaced viscera as a result of other developmental abnormalities, such as gastroschisis, omphalocele, or congenital diaphragmatic hernia, predispose to malrotation.

Malrotation is also associated with duodenal atresia, Meckel diverticulum, intussusception, small bowel atresia, prune belly syndrome, gastric volvulus, persistent cloaca, Hirschsprung disease, and extrahepatic biliary anomalies.

In contrast to midgut volvulus, sigmoid volvulus is usually the result of a dilated rectosigmoid colon on a narrow pedicle.

Frequency

United States

An incidence of 1 in 500 live births has been reported for malrotation with midgut volvulus.

International

Sigmoid volvulus is more common in developing nations than in the United States, likely because of dietary differences in terms of fiber. Chagas disease in Brazil may account for a significant proportion of cases in that country.

Mortality/Morbidity

See Complications.

Sex

No sex predilection is known; however, midgut volvulus predominates in male infants, with a male-to-female ratio of 2:1 in the neonatal period.

Age

Of those in whom volvulus occurs, 68-71% are neonates. Most cases occur by age 2 months, but as many as 41% of cases occur at an older age.

Approximately 40% of infants with malrotation develop symptoms within the first week after birth; 50% present within the first month, 75% present before age 1 year, and the remaining 25% present after age 1 year.


CLINICAL

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History

Clinical presentation of these patients varies.

  • In the first month of life, the most typical presentation includes feeding intolerance or bilious vomiting and sudden onset of abdominal pain. Bilious vomiting is the hallmark presentation and is observed 77-100% of the time. In infants of this age, consider such a presentation diagnostic of malrotation with midgut volvulus until proven otherwise. In older children, symptoms can be vague and may include chronic intermittent vomiting and abdominal cramping, failure to thrive, constipation, bloody diarrhea, and hematemesis.
  • Children with vague clinical features are sometimes incorrectly diagnosed as having irritable bowel syndrome, peptic ulcer disease, kidney stones, or even psychogenic or emotional disorders.
  • Sigmoid volvulus typically presents with abdominal pain, distention, and inability to pass stool or flatus (obstipation). Vomiting may be a late presenting feature, and cases may progress to peritonitis, sepsis, and death.

Physical

  • In early cases, patients may appear well, and abdominal examination findings may be normal. In fact, normal findings on abdominal examination have been reported in as many as 50% of patients. In one series, 32% of patients had abdominal distension but no tenderness.
  • Patients who present acutely usually have pain out of proportion to the degree of abdominal tenderness.
  • Because the obstruction is very proximal, abdominal distension is not usually present.
  • Careful examination may reveal a palpable abdominal mass in some patients.
  • Signs of intraluminal blood loss, such as hematochezia or stool guaiac testing, are usually positive.
  • A high index of suspicion is required to establish the diagnosis at an early stage. If the diagnosis is missed, intestinal ischemia progresses to gangrene, and bowel distension from gas-producing organisms within the intestine occurs.
  • Once ischemia occurs, almost all patients develop diffuse and severe abdominal pain and signs of peritonitis. Patients with gangrene are usually tachycardic and hypovolemic. Passage of blood or sloughed mucosal tissue may be noted as vascular compromise progresses.
  • As ischemia progresses to infarction and necrosis, fever, peritonitis, abdominal distension, profound hypovolemia, and septic shock develop.


DIFFERENTIALS

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Cholecystitis
Constipation
Gastroenteritis
Hepatitis B
Hirschsprung Disease
Intussusception
Meckel Diverticulum

Other Problems to be Considered

Appendicitis
Bowel obstruction
Colic
Henoch-Schönlein purpura
Incarcerated hernia
Necrotizing enterocolitis
Ovarian torsion
Pancreatitis
Peptic ulcer
Perforated viscus
Renal stones
Sickle cell crisis
Urinary tract infection


WORKUP

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Lab Studies

  • Laboratory tests should not delay immediate surgical consultation and operation when volvulus is suspected; no laboratory tests are specific for this problem.  
  • A CBC count, clotting studies, electrolyte level tests, and blood glucose level tests are usually sufficient for preoperative evaluation.

Imaging Studies

  • Plain radiography
    • Flat, upright, and cross-table lateral radiographs of the abdomen may reveal evidence of small bowel obstruction, including dilated small-bowel loops; marked gastric or proximal duodenal dilatation, with or without intestinal gas; and air-fluid levels.
    • The double bubble sign, indicative of gastric and duodenal dilatation, can be demonstrated on a simple air contrast study (see Media file 1).
    • In early cases, plain abdominal radiography may not be helpful, but oral contrast studies may reveal intestinal obstruction.
    • In contrast to midgut volvulus, plain radiography may reveal a distended sigmoid colon characteristic to sigmoid volvulus. 
  • Upper GI imaging
    • Although the issue of upper versus lower GI contrast studies is controversial, most centers prefer upper GI imaging (UGI) series for the radiologic evaluation of malrotation and midgut volvulus.
    • In patients who are stable, most centers perform an UGI series.
    • Malrotation with midgut volvulus is suspected when the duodenojejunal junction is in an abnormal location and/or an abrupt ending or corkscrew tapering of contrast is present, signifying proximal intestinal obstruction (see Media file 2).
    • Specificity of UGI studies in detecting malrotation is 100%, but the sensitivity for detecting midgut volvulus is only 54%, reflecting the importance of clinical judgment in diagnosis.
  • Lower GI imaging
    • When the results of UGI studies are equivocal, a lower GI imaging (LGI) contrast study may be used to identify malrotation. However, the results are not reliable if a midgut volvulus is present.
    • In patients with bilious vomiting and a low clinical suspicion for midgut volvulus, LGI may be used to rule out colonic obstruction due to conditions such as atresia, Hirschsprung disease, and meconium ileus and/or meconium plug and may actually prove to be therapeutic.
    • Important findings on LGI include demonstration of the cecum and proximal colon in the left flank.
    • Failure to recognize malrotation has been observed with LGI studies in 5-20% of patients with a normally located cecum.
    • LGI reveals dilated rectosigmoid loops with an abrupt inability to pass contrast beyond obstruction in patients with sigmoid volvulus.
  • Ultrasonography
    • Usually, this test is not very helpful in evaluating patients.
    • In some cases, ultrasonography may reveal intraluminal fluid or edema in the bowel wall. If performed for other reasons, it may reveal persistent distension of the duodenum as it courses around the head of the pancreas.
    • In many patients with malrotation, the normal anatomical relationship between the SMA and vein is altered, and the artery lies anterior or even to the right of the superior mesenteric vein. On the other hand, a normal anatomical relationship between these structures does not rule out the possibility of malrotation.
  • CT scanning
    • Abdominal contrast CT has a high sensitivity for demonstrating small bowel obstruction.2
    • The finding of multiple and posterior location of transition points within the small bowel (segments where dilated small bowel is immediately followed by collapsed bowel) is predictive of volvulus.
    • The "whirl sign" (clockwise or counterclockwise twisting of the bowel that extends for at least 180º) can also be seen using CT scanning in cases of volvulus.


TREATMENT

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Medical Care

Immediate surgical consultation is necessary in patients with volvulus.

  • Aggressive fluid resuscitation is indicated while awaiting surgical intervention.
  • Nasogastric decompression may be successful in alleviating vomiting and discomfort associated with obstruction.
  • Rectal tube decompression of the sigmoid volvulus can be achieved. This may be aided by endoscopic placement. 

Surgical Care

Do not delay operation in a patient who is not stable.

  • During operation, the midgut volvulus is reduced by untwisting the bowel in a counterclockwise fashion. Viability of the small bowel loops can then be assessed (see Media file 3).
  • Doppler probe or fluorescein with a Wood light may be helpful in documenting the viability of the bowel. Necrotic bowel is resected if it is encountered.
  • Most patients undergo the Ladd procedure (ie, appendectomy, division of mesenteric bands, and placement of the small intestine on the right and the colon on the left side of the abdomen). A laparoscopic Ladd procedure has been described with good success rates.3
  • Patients with questionable viability of a significant length of unresected bowel after the initial operation may require a second-look procedure 24 hours later to reevaluate the viability of the bowel.
  • Definitive treatment for sigmoid volvulus remains surgical with resection and primary anastomosis. As with most instances of bowel resection, an open approach is usually used.
  • Postoperatively, patients still require aggressive fluid resuscitation and intravenous (IV) antibiotics. IV parenteral nutrition is begun in patients that have undergone resection of a significant length of bowel.
  • When the entire bowel appears necrotic, massive resection typically results in short bowel syndrome and a lifetime of parenteral nutrition with its associated morbidities, most notably progressive cholestatic liver disease.
  • Small bowel transplant for short bowel syndrome continues to be associated with high morbidity and mortality, although increasing experience and advances in immunosuppressive therapy continue to increase the survival rates in children. Early listing with a small bowel transplant service before the development of end-stage liver disease may result in improved outcome after transplant.


MEDICATION

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Broad-spectrum antibiotics, such as ampicillin, clindamycin, and gentamicin or cefotetan, should be administered to the patients in whom vascular compromise, bowel necrosis, perforation, or sepsis is suspected. These agents have proven effective in decreasing the rate of postoperative wound infection and improving outcome.

Drug Category: Antibiotics

Empiric initial antimicrobial therapy must be comprehensive and should cover all likely pathogens in the clinical setting.

Drug NameAmpicillin (Principen)
DescriptionInterferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms.
Adult Dose1-2 g/d PO divided q6h; 2-8 g/d IV/IM divided q4-6h
Pediatric Dose50 mg/kg/dose IV/IM q6h
ContraindicationsDocumented hypersensitivity
InteractionsIncreased blood concentrations with probenecid; may decreased effectiveness of PO contraceptives
PregnancyB - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
PrecautionsAdjust dose with renal failure; evaluate carefully to differentiate a nonallergic ampicillin rash from a hypersensitivity reaction

Drug NameGentamicin (Garamycin)
DescriptionIf used in combination with an antianaerobic agent, such as metronidazole, gentamicin provides broad gram-negative and anaerobic coverage. Dosing regimens are numerous and are adjusted based on creatinine clearance and changes in the volume of distribution.
Adult Dose2 mg/kg IV loading dose prior to surgery; then 3-5 mg/kg/d IV divided q8h
Pediatric DoseInfants/neonates: 7.5 mg/kg/d IV divided q8h
Children: 6-7.5 mg/kg/d IV divided q8h
ContraindicationsDocumented hypersensitivity; non–dialysis-dependent renal insufficiency
InteractionsCoadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; because aminoglycosides enhance effects of neuromuscular blocking agents prolonged respiratory depression may occur; coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)
PregnancyD - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
PrecautionsNot for long-term therapy because of narrow therapeutic index and toxicity associated with extended administration; caution in patients diagnosed with renal failure (patient not on dialysis), hypocalcemia, myasthenia gravis, and conditions that depress neuromuscular transmission; adjust dose with renal impairment

Drug NameClindamycin (Cleocin)
DescriptionUseful as a treatment against serious skin and soft tissue infections caused by most staphylococci strains. Is also effective against aerobic and anaerobic streptococci, except for enterococci. Inhibits bacterial protein synthesis by inhibiting peptide chain initiation at the bacterial ribosome, where it preferentially binds to the 50S ribosomal subunit, causing bacterial replication inhibition.
Adult Dose300-900 mg IV/IM q6-12h; not to exceed 4800 mg/d
Pediatric DoseMild infection: 8-16 mg/kg/d IV/IM divided tid/qid
Serious infection: 16-20 mg/kg/d IV/IM divided tid/qid
ContraindicationsDocumented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis
InteractionsIncreases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin
PregnancyB - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
PrecautionsAdjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile

Drug NameCefotetan (Cefotan)
DescriptionA second-generation cephalosporin used as single-drug therapy to provide broad gram-negative coverage and anaerobic coverage. The half-life is 3.5 h.
Adult Dose2 g IV prior to surgery, then 1-2 g IV/IM q12h for 5-10 d
Pediatric Dose20-40 mg/kg/dose IV/IM q12h for 5-10 d
ContraindicationsDocumented hypersensitivity
InteractionsConsumption of alcohol within 72 h of cefotetan may produce disulfiramlike reactions; cefotetan may increase hypoprothrombinemic effects of anticoagulants; coadministration with potent diuretics (eg, loop diuretics) or aminoglycosides may increase nephrotoxicity
PregnancyB - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
PrecautionsReduce dosage by half for patients with creatinine clearance of 10-30 mL/min and by one fourth for patients with creatinine clearance <10 mL/min; use of antibiotics (especially prolonged or repeated therapy) may result in bacterial or fungal overgrowth of nonsusceptible organisms, possibly leading to secondary infection; take appropriate measures if superinfection occurs


FOLLOW-UP

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Further Inpatient Care

  • All patients with acute presentations require admission to the hospital.
  • Individuals with GI hemorrhage or shock require volume resuscitation, urgent surgical presentation, and intensive care in the postoperative period.

Complications

  • Midgut volvulus has a mortality rate of 3-15%.
    • Delay in operation leads to higher mortality rates.
    • Usually, the lower acceptable limit of bowel length is considered 25 cm with an intact ileocecal valve and 42 cm without an ileocecal valve.
    • In patients with bowel necrosis, the length of bowel resected also determines survival. Messineo et al demonstrated this in a 1992 study of 182 patients undergoing laparotomy for malrotation, in which they found a 0.999 estimated probability of survival in patients with 10% bowel necrosis, a 0.920 estimated probability in patients with 50% necrosis, and a 0.351 estimated probability in patients with 75% necrosis.4
  • Short gut syndrome, with its inherent complications of long-term parenteral nutrition (eg, line sepsis, growth retardation, hepatobiliary dysfunction), is associated with high morbidity and mortality.
  • Prognosis of midgut volvulus depends on prompt recognition before bowel necrosis occurs. All these complications can be prevented by operation on incidentally discovered malrotation in asymptomatic patients.

Prognosis


MISCELLANEOUS

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Medical/Legal Pitfalls

  • Consider unexplained bilious vomiting in an otherwise healthy infant a surgical emergency; likewise, assume malrotation with midgut volvulus until proven otherwise.
  • Some would consider the use of prokinetics in infants inadvisable until imaging has ruled out intestinal malrotation.
  • Devastating medical and legal complications in these patients can be prevented if this diagnosis is considered in any patient with abdominal pain and signs of intestinal obstruction.


FURTHER READING

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For more information, see the eMedicine article Sigmoid Volvulus.


MULTIMEDIA

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Media file 1:  Plain abdominal radiograph shows dilated stomach and proximal bowel with some air distally (ie, the double bubble sign).
Click to see larger pictureClick to see detailView Full Size Image
 
Media type:  Radiograph

Media file 2:  Lateral view from an upper GI imaging series reveals duodenum with a corkscrew appearance.
Click to see larger pictureClick to see detailView Full Size Image
 
Media type:  Radiograph

Media file 3:  Operative findings of malrotation of the gut with volvulus.
Click to see larger pictureClick to see detailView Full Size Image
 
Media type:  Photo


REFERENCES

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  1. Houshian S, Sorensen JS, Jensen KE. Volvulus of the transverse colon in children. J Pediatr Surg. Sep 1998;33(9):1399-401. [Medline].
  2. Jabra AA, Fishman EK. Small bowel obstruction in the pediatric patient: CT evaluation. Abdom Imaging. Sep-Oct 1997;22(5):466-70. [Medline].
  3. Bax NM, van der Zee DC. Laparoscopic treatment of intestinal malrotation in children. Surg Endosc. Nov 1998;12(11):1314-6. [Medline].
  4. Messineo A, MacMillan JH, Palder SB. Clinical factors affecting mortality in children with malrotation of the intestine. J Pediatr Surg. Oct 1992;27(10):1343-5. [Medline].
  5. Ameh EA, Nmadu PT. Intestinal volvulus: aetiology, morbidity, and mortality in Nigerian children. Pediatr Surg Int. 2000;16(1-2):50-2. [Medline].
  6. Anatol TI. Intestinal malrotation in Trinidad. J R Coll Surg Edinb. Jun 1992;37(3):172-4. [Medline].
  7. Andersen JF, Eklof O, Thomasson B. Large bowel volvulus in children. Review of a case material and the literature. Pediatr Radiol. 1981;11(3):129-38. [Medline].
  8. Andrassy RJ, Mahour GH. Malrotation of the midgut in infants and children: a 25-year review. Arch Surg. Feb 1981;116(2):158-60. [Medline].
  9. Black PR, Mueller D, Crow J. Mesenteric defects as a cause of intestinal volvulus without malrotation and as the possible primary etiology of intestinal atresia. J Pediatr Surg. Oct 1994;29(10):1339-43. [Medline].
  10. Bonadio WA, Clarkson T, Naus J. The clinical features of children with malrotation of the intestine. Pediatr Emerg Care. Dec 1991;7(6):348-9. [Medline].
  11. Boulton JE, Ein SH, Reilly BJ. Necrotizing enterocolitis and volvulus in the premature neonate. J Pediatr Surg. Sep 1989;24(9):901-5. [Medline].
  12. de Agustin JC, Vazquez JJ, Rodriguez-Arnao D. Severe short-bowel syndrome in children. Clinical experience. Eur J Pediatr Surg. Aug 1999;9(4):236-41. [Medline].
  13. Ditchfield MR, Hutson JM. Intestinal rotational abnormalities in polysplenia and asplenia syndromes. Pediatr Radiol. May 1998;28(5):303-6. [Medline].
  14. Feitz R, Vos A. Malrotation: the postoperative period. J Pediatr Surg. Sep 1997;32(9):1322-4. [Medline].
  15. Ford EG, Senac MO Jr, Srikanth MS. Malrotation of the intestine in children. Ann Surg. Feb 1992;215(2):172-8. [Medline].
  16. Gambarara M, Ferretti F, Bagolan P. Ultra-short-bowel syndrome is not an absolute indication to small-bowel transplantation in childhood. Eur J Pediatr Surg. Aug 1999;9(4):267-70. [Medline].
  17. Gauderer MW. Acute abdomen. When to operate immediately and when to observe. Semin Pediatr Surg. May 1997;6(2):74-80. [Medline].
  18. Goulet OJ, Revillon Y, Jan D. Neonatal short bowel syndrome. J Pediatr. Jul 1991;119(1 ( Pt 1)):18-23. [Medline].
  19. Houben CH, Hiorns MP. Re: "Is ultrasonography a good screening test for intestinal malrotation?" by Orzech et al. J Pediatr Surg. Oct 2007;42(10):1795. [Medline].
  20. Ikeda H, Matsuyama S, Suzuki N. Small bowel obstruction in children: review of 10 years experience. Acta Paediatr Jpn. Dec 1993;35(6):504-7. [Medline].
  21. Ismail A. Recurrent colonic volvulus in children. J Pediatr Surg. Dec 1997;32(12):1739-42. [Medline].
  22. Kalfa N, Zamfir C, Lopez M. Conditions required for laparoscopic repair of subacute volvulus of the midgut in neonates with intestinal malrotation: 5 cases. Surg Endosc. Dec 2004;18(12):1815-7. [Medline].
  23. Kealey WD, McCallion WA, Brown S. Midgut volvulus in children. Br J Surg. Jan 1996;83(1):105-6. [Medline].
  24. Liu KK, Leung MW, Wong BP, Chao NS, Chung KW, Kwok WK. Minimal access surgery for sigmoid volvulus in children. Pediatr Surg Int. Dec 2006;22(12):1007-8. [Medline].
  25. Long FR, Kramer SS, Markowitz RI. Radiographic patterns of intestinal malrotation in children. Radiographics. May 1996;16(3):547-56; discussion 556-60. [Medline].
  26. Malek MM, Burd RS. Surgical treatment of malrotation after infancy: a population-based study. J Pediatr Surg. Jan 2005;40(1):285-9. [Medline].
  27. Matsuo Y, Nezu R, Kubota A. Massive small bowel resection in neonates--is weaning from parenteral nutrition the final goal?. Surg Today. 1992;22(1):40-5. [Medline].
  28. Maung M, Saing H. Intestinal volvulus: an experience in a developing country. J Pediatr Surg. May 1995;30(5):679-81. [Medline].
  29. Maxson RT, Franklin PA, Wagner CW. Malrotation in the older child: surgical management, treatment, and outcome. Am Surg. Feb 1995;61(2):135-8. [Medline].
  30. McVay MR, Kokoska ER, Jackson RJ, Smith SD. Jack Barney Award. The changing spectrum of intestinal malrotation: diagnosis and management. Am J Surg. Dec 2007;194(6):712-7; discussion 718-9. [Medline].
  31. Mellor MF, Drake DG. Colonic volvulus in children: value of barium enema for diagnosis and treatment in 14 children. AJR Am J Roentgenol. May 1994;162(5):1157-9. [Medline].
  32. Neilson IR, Youssef S. Delayed presentation of Hirschsprung's disease: acute obstruction secondary to megacolon with transverse colonic volvulus. J Pediatr Surg. Nov 1990;25(11):1177-9. [Medline].
  33. Palanivelu C, Rangarajan M, Shetty AR, Jani K. Intestinal malrotation with midgut volvulus presenting as acute abdomen in children: value of diagnostic and therapeutic laparoscopy. J Laparoendosc Adv Surg Tech A. Aug 2007;17(4):490-2. [Medline].
  34. Powell DM, Othersen HB, Smith CD. Malrotation of the intestines in children: the effect of age on presentation and therapy. J Pediatr Surg. Aug 1989;24(8):777-80. [Medline].
  35. Prasil P, Flageole H, Shaw KS. Should malrotation in children be treated differently according to age?. J Pediatr Surg. May 2000;35(5):756-8. [Medline].
  36. Rescorla FJ, Shedd FJ, Grosfeld JL. Anomalies of intestinal rotation in childhood: analysis of 447 cases. Surgery. Oct 1990;108(4):710-5; discussion 715-6. [Medline].
  37. Salas S, Angel CA, Salas N. Sigmoid volvulus in children and adolescents. J Am Coll Surg. Jun 2000;190(6):717-23. [Medline].
  38. Samuel M, Wheeler RA, Mami AG. Does duodenal atresia and stenosis prevent midgut volvulus in malrotation?. Eur J Pediatr Surg. Feb 1997;7(1):11-2. [Medline].
  39. Sandhu PS, Joe BN, Coakley FV, Qayyum A, Webb EM, Yeh BM. Bowel transition points: multiplicity and posterior location at CT are associated with small-bowel volvulus. Radiology. Oct 2007;245(1):160-7. [Medline].
  40. Seashore JH, Touloukian RJ. Midgut volvulus. An ever-present threat. Arch Pediatr Adolesc Med. Jan 1994;148(1):43-6. [Medline].
  41. Senocak ME, Buyukpamukcu N, Hicsonmez A. Massive paraesophageal hiatus hernia containing colon and stomach with organo-axial volvulus in a child. Turk J Pediatr. Jan-Mar 1990;32(1):53-8. [Medline].
  42. Shimanuki Y, Aihara T, Takano H. Clockwise whirlpool sign at color Doppler US: an objective and definite sign of midgut volvulus. Radiology. Apr 1996;199(1):261-4. [Medline].
  43. Siegel MJ, Shackelford GD, McAlister WH. Small bowel volvulus in children: its appearance on the barium enema examination. Pediatr Radiol. Nov 1980;10(2):91-3. [Medline].
  44. Smith SD, Golladay ES, Wagner C. Sigmoid volvulus in childhood. South Med J. Jul 1990;83(7):778-81. [Medline].
  45. Stauffer UG, Herrmann P. Comparison of late results in patients with corrected intestinal malrotation with and without fixation of the mesentery. J Pediatr Surg. Feb 1980;15(1):9-12. [Medline].
  46. Sule AZ, Misauno M, Opaluwa AS, Ojo E, Obekpa PO. One stage procedure in the management of acute sigmoid volvulus without colonic lavage. Surgeon. Oct 2007;5(5):268-70. [Medline].
  47. Tabassum HM, Ch MA, Bukhari MA. Small bowel volvulus leading to gangrene and short bowel syndrome. J Coll Physicians Surg Pak. Jan 2005;15(1):55-6. [Medline].
  48. Torres AM, Ziegler MM. Malrotation of the intestine. World J Surg. May-Jun 1993;17(3):326-31. [Medline].
  49. Uba AF, Chirdan LB, Edino ST. Intestinal malrotation: presentation in the older child. Niger J Med. Jan-Mar 2005;14(1):23-6. [Medline].
  50. Waldhausen JH, Sawin RS. Laparoscopic Ladd's procedure and assessment of malrotation. J Laparoendosc Surg. Mar 1996;6 Suppl 1:S103-5. [Medline].
  51. Waseem M, Hipp A. Megacolon: constipation or volvulus?. Pediatr Emerg Care. May 2006;22(5):346-8. [Medline].
  52. Weber TR, Tracy T Jr, Connors RH. Short-bowel syndrome in children. Quality of life in an era of improved survival. Arch Surg. Jul 1991;126(7):841-6. [Medline].
  53. Wiersma R, Hadley GP. Small bowel volvulus complicating intestinal ascariasis in children. Br J Surg. Jan 1988;75(1):86-7. [Medline].
  54. Yamashita H, Kato H, Uyama S. Laparoscopic repair of intestinal malrotation complicated by midgut volvulus. Surg Endosc. Nov 1999;13(11):1160-2. [Medline].

Volvulus excerpt

Article Last Updated: May 13, 2008