Volvulus (peds)

This page is for pediatric patients. For adult patients, see: volvulus.

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
  • Necrotizing Enterocolitis
  • Volvulus
  • Testicular torsion
  • Inguinal hernia
    • Incarcerated hernia
  • Trauma
  • Pyloric stenosis
  • Toxic megacolon
  • Hirschsprung's Disease
• Nonemergent
  • Constipation
  • Acute Gastroenteritis
  • Colic

3 mo–3 y old

• Emergent
  • Intussusception
  • Testicular Torsion
  • Trauma
  • Volvulus
  • Appendicitis
  • Toxic megacolon
  • Vaso-occlusive crisis
• Nonemergent
  • Acute Gastroenteritis
  • Constipation
  • Urinary tract infection
  • Henoch-Schonlein purpura

3 y old–adolescence

• Emergent
  • Appendicitis
  • DKA
  • Vaso-occlusive crisis
  • Toxic ingestion
  • Testicular Torsion
  • Ovarian Torsion
  • Ectopic Pregnancy
  • Trauma
  • Toxic megacolon
  • Inflammatory bowel disease
  • Gastric ulcer disease
  • Ovarian cyst
  • Pregnancy
  • Pancreatitis
  • Cholecystitis
  • Intussusception (to age 6)
• Nonemergent
  • Constipation
  • Acute Gastroenteritis
  • Nonspecific viral syndrome
  • Streptococcus pharyngitis
  • Urinary tract infection
  • Pneumonia
  • Renal Stone
  • Henoch-Schonlein purpura
  • Inflammatory bowel disease
  • Vulvovaginitis

Constipation

• Behavioral-related
  • Lack of exercise
  • Diet-related
• Fecal impaction
  • Stercoral colitis
• Ileus from surgical abdomen
  • Appendicitis
  • Diverticulitis
• Bowel obstruction
  • Small bowel obstruction
  • Large bowel obstruction
    • Ogilvie's syndrome
  • Malignant bowel obstruction
  • Specific causes: tumor, stricture, hernia, adhesion, volvulus
• Painful anorectal disorders (e.g. anal fissure, hemorrhoids)
• Medical causes
  • Hypothyroidism
  • Electrolytes
    • Hypomagnesia
    • Hypercalcemia
  • Hypokalemia
• Medication-related
  • Opiods, antipsychotics, anticholinergics, antacid, antihistamines
• Constipation (peds)

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 gas
  • Cecal volvulus
    • May see findings similar to small bowel obstruction
      • Air-fluid level, paucity of gas
    • Distended loop of colon with haustral markings
  • 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
• 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

See Also

• Abdominal Pain (Peds)
• Volvulus (Adults)