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Volvulus (peds)
From WikEM
Contents
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%
Clinical Features
- 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
Differential Diagnosis
Pediatric Abdominal Pain
0–3 Months Old
- Emergent
- Nonemergent
3 mo–3 y old
- Emergent
- Nonemergent
3 y old–adolescence
- Emergent
- Nonemergent
Evaluation
Imaging
- Should not delay surgical consult
- Abdominal XR
- 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
- May see findings similar to small bowel obstruction
- 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
- Upper GI with contrast
- Sigmoid volvulus
- CT Abd/pelvis
- Highly sensitive and specific for volvulus
- Usually not necessary in cecal volvulus
- May be helpful in diagnosis of sigmoid volvulus, look for "whirl sign"
Management
- Emergent surgical consult
- Place NG tube
- Fluid 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
Disposition
- Admit
