MALROTATION / MIDGUT VOLVULUS

Question 1

Approach to the Critically Ill Suspected Malrotation / Midgut Volvulus

Answer 1

Crystalloid fluid bolus 20 ml/kg

Maintenance Fluid D5 0.45% NS

4 cc/kg/hr for 1st 10 kg
2 cc/kg/hr for 10-20 kg
1 cc/kg/hr for every kg > 20 kg

KCl @ 0.5 mEq/kg/hr IV

Serum potassium <3mEq/L give total of 1 mEq/kg (up to adult dose)
Serum potassium 3-3.5 mEq/L give 0.2 mEq/kg and recheck
Dopamine: 3 μg/kg/min, titrate to effect

Obtain i-STAT labs, including glucose.

Analgesia:
morphine 0.05-0.1 mg/kg IV
OR
fentanyl 1 μg/kg IV

Ondansetron:
2 mg < 15 kg
4 mg > 15 kg
8 mg > 30 kg

NG tube to low intermittent suction if gastric distension is present

Supine and upright / lateral decubitus abdominal radiographs

Pediatric surgical consultation

Question 2

Pathophysiology

Answer 2

Loop of bowel twists about the mesenteric attachment -> ischemia -> necrosis

Question 3

Epidemiology

Answer 3

MC < 1 yr of life

Question 4

History & Physical

Answer 4

BILIOUS VOMITING in a neonate / infant = Volvulus

75% diagnosed in neonatal period

Minimal Distended and Constant Severe Abdominal Pain (due to high obstruction) (90%)

Shock a/w necrotic or ischemic bowel

Question 5

Investigations

Answer 5

CBC
Lytes
Cr
Type & Screen
+/- Hemoccult stool

Upper GI Series: assess the d-j junction. Corkscrew appearance.

Ultrasound: May show superior mesenteric artery and vein in opposite positions. Doppler may show “whirlpool sign” - the mesenteric artery swirling around the vein (sn 86% sp 92%)

Plain XRAY:
- double bubble sign (air in stomach & duodenum)
- signs of obstruction: paucity of gas, air fluid levels, dilated loops of bowel