A 3-Day-Old Boy With Bilious Emesis

Jamie Shalkow, MD


April 14, 2016

The initial management of suspected midgut volvulus should include fluid resuscitation, nasogastric suctioning, and imaging with plain radiography.[2] Radiographic findings may include the "double bubble" sign, which is evidence of a proximal small bowel obstruction or a gasless abdomen (Figure 2; image shown is an example of malrotation without volvulus, and not from the actual patient). Blood should be sent to the laboratory for a complete blood cell count (CBC) and metabolic panel. A finding of acidosis should raise suspicion.[6]

Figure 2.

Figure 3.

Figure 4.

The confirmatory diagnostic studies of choice for midgut volvulus are either an upper gastrointestinal contrast study or a barium enema. As soon as the diagnosis of volvulus is seriously considered, a general surgeon should be contacted to discuss management and to expedite both confirmatory studies and definitive care. This condition is a true surgical emergency, with a mortality of approximately 15% and, when surgery is delayed, significant morbidity associated with necessary resection of ischemic bowel.

Most pediatric surgeons will prefer the upper gastrointestinal study because it confirms the position of the ligament of Treitz and demonstrates small bowel loops hanging completely into the right side of the abdomen (Figure 3).[2] The duodenal loop will be dilated and obstructed (corkscrew appearance), it will lack the classic "C" shape, and it won't cross the spine back into its normal left-sided location. A barium enema may demonstrate a cecum that is not in its normal right lower quadrant position (Figure 4). An upper gastrointestinal study is preferable because malrotation includes a spectrum of conditions which may prevent the intestine from being completely nonrotated. In some cases, the bowel may be only partially rotated, which can be missed on a barium enema.[1] Doppler ultrasonography may also be useful for assessing the vascular flow in the superior mesenteric artery and confirming the abnormal position of the superior mesenteric vein (which is normally to the right of the superior mesenteric artery).[5] Ultrasonography can also identify a fluid-filled, distended duodenum and small bowel loops exclusively to the right of the midline.


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