That’s Twisted – A Review of Pediatric Volvulus

October 3, 2024

Written by Joshua Belfer

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Pediatric volvulus is associated with a high morbidity and mortality rate but remains a challenging diagnosis. This review highlights pearls and pitfalls of diagnosis and management.

A twist, then a shout…
Volvulus is the twist of the gastrointestinal tract on itself and can occur at both the gastric level and midgut level. Gastric volvulus occurs with the twisting of the stomach, while midgut volvulus most commonly results from malrotation that leads to intestinal twisting. If not promptly diagnosed, both forms can lead to GI tract ischemia and perforation.

Presentation:
While historically thought about as a disease of infancy, all ages can be affected. Gastric volvulus presents with retching either without emesis or with non-bilious emesis. Suspicion can be raised by observing Borchardt’s Triad: inability to pass an NG tube, retching without emesis, and abdominal distension. Midgut volvulus occurs overwhelmingly in infants <1 month of age and presents with emesis that is typically bilious. Vomiting can result in dehydration, and while older patients tend to present with abdominal pain and sometimes constipation, infants may present with lethargy and fussiness.

Workup:
Plain radiographs in gastric volvulus may show abnormalities including a horizontal or spherical stomach along with one or two air-fluid levels. If available, an upper GI contrast series is the modality of choice. Similarly, for midgut volvulus, an upper GI study is the gold standard. Abnormalities can be seen on plain radiographs, including multiple air-fluid levels or a “double bubble” sign similar to duodenal atresia. In severe cases of volvulus with ischemia, pneumatosis may be seen on radiographs.

Management:
Patients with volvulus require emergent pediatric surgical consultation. While operative intervention is ultimately (and quickly!) required, fluid resuscitation, IV antibiotics, and cautious placement of an OG or NG tube is used to help stabilize the patient.

Pearls and Pitfalls:

• Congenital abnormalities are present in up to 100% of volvulus patients, with congenital diaphragmatic hernia being the most common.
• Early in the presentation, patients can present with a flat abdomen that then becomes distended.
• False positive imaging can be seen in children <4 years old due to variation in the location of the duodenojejunal junction.
• A normal abdominal radiograph does not exclude malrotation or volvulus.
• Ultrasound can be used for diagnosis.

How will this change my practice?
Given that the majority of midgut volvulus presents in the first month of life, I always include it in the differential for a young infant with vomiting; if the vomiting is bilious, the child has volvulus until proven otherwise. While the classic presentation is bilious emesis, it should also be considered with nonbilious emesis, and certainly if the vomiting is causing significant dehydration. This article does a great job in reviewing the presentation of gastric volvulus, which is less common and can be more difficult to diagnose. A low threshold for imaging young infants with vomiting can help make this diagnosis, although if there is high enough suspicion, patients may need to be transferred to a pediatric center for an upper GI series. Vomiting is a relatively common presentation for infants in the ED, but volvulus is a “can’t miss” diagnosis that can present with non-specific symptoms.

Source
High risk and low incidence diseases: Pediatric digestive volvulus. Am J Emerg Med. 2024 Aug;82:153-160. doi: 10.1016/j.ajem.2024.06.012. Epub 2024 Jun 14. PMID: 38908340.