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Midgut volvulus. An ever-present threat
1Department of Surgery, Yale University School of Medicine, New Haven, Conn.
Objective:
To identify risk factors for midgut volvulus (MGV) and to seek clues to early diagnosis of MGV in children with malrotation.
Design:
Retrospective patient series.
Setting:
Academic medical center.
Patients:
Sixty-eight consecutive children who had a Ladd operation performed between January 1970 and December 1991. Excluded were three patients whose records were unavailable and patients who had a Ladd operation during the course of repair of an abdominal wall defect or congenital diaphragmatic hernia.
Results:
Forty of 68 patients had MGV at operation. There was an inverse correlation between age at onset of symptoms and the probability of MGV: 85% (29/34) of patients less than 1 month of age had MGV compared with 43% (10/23) of older children. Patients who had symptoms for less than 4 days were more likely to have MGV (88%; 30/34) than patients who had more chronic symptoms (43%; 10/23). Bilious (green) vomiting was more highly associated with MGV (80%; 35/44) than nonbilious vomiting (38%; 3/8) or pain (50%; 6/12). Roentgenograms of the upper gastrointestinal tract were very accurate for the diagnosis of malrotation but frequently failed to identify MGV (sensitivity, 54%; 13/24). Despite the high proportion of MGV, only three patients had gangrenous bowel. Of these three patients, one died and two have short-gut syndrome.
Conclusion:
Neonates with a short history of bilious vomiting are most likely to have MGV-complicating malrotation, but older children who have chronic intermittent symptoms are also at risk. Since there is no way to predict which patients will develop catastrophic bowel necrosis, early diagnosis and operation are necessary to prevent mortality and short-gut syndrome.
Insights
Infants with malrotation and short-term bilious vomiting are at high risk for midgut volvulus (MGV). Early diagnosis and surgery are crucial for preventing mortality and short-gut syndrome in children with malrotation.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Developmental Biology
Background:
- Malrotation is a congenital anomaly of intestinal rotation during fetal development.
- Midgut volvulus (MGV) is a surgical emergency that can occur in children with malrotation, leading to intestinal ischemia.
- Early diagnosis and intervention are critical to prevent severe complications.
Purpose of the Study:
- To identify risk factors associated with midgut volvulus (MGV) in pediatric patients with intestinal malrotation.
- To discover clinical and diagnostic clues for the early identification of MGV in this population.
Main Methods:
- Retrospective analysis of 68 children who underwent a Ladd operation for malrotation.
- Data collected on patient age, symptom duration, vomiting characteristics, and diagnostic imaging findings.
- Correlation of clinical factors with the presence of MGV at surgery.
Main Results:
- Midgut volvulus (MGV) was present in 40 of 68 patients (59%).
- Younger age (less than 1 month) and shorter symptom duration (less than 4 days) were significantly associated with MGV.
- Bilious vomiting was a stronger indicator of MGV than non-bilious vomiting or pain.
- Upper GI series had limited sensitivity (54%) for diagnosing MGV, despite high accuracy for malrotation.
Conclusions:
- Neonates presenting with acute bilious vomiting and malrotation have a high likelihood of concurrent MGV.
- Older children with chronic, intermittent symptoms also remain at risk for MGV.
- Prompt surgical intervention is essential due to the unpredictable risk of catastrophic bowel necrosis, mortality, and short-gut syndrome.