Malrotation and volvulus — formative SAQs

SAQ 1 (10)

A three-day-old term baby, who fed and stooled normally in hospital and was discharged home, is brought to the emergency department after vomiting a mouthful of bright green fluid. On examination the baby is alert and afebrile, with a soft and only slightly full abdomen, normal femoral pulses and no hernial or perineal abnormality. The plain abdominal radiograph is reported as unremarkable. The admitting team documents the vomit as bilious. ^{[1] [2]}

a) State the governing clinical rule that should drive this baby's management, and explain why a well-looking baby with a normal plain film does not lower the suspicion of midgut volvulus. (3 marks) ^{[1] [2]}

b) Outline the immediate resuscitation and stabilisation, including the fluid bolus you would give for shock, nasogastric management, and the indication for antibiotics. (3 marks) ^[2]

c) Name the reference imaging investigation, state the diagnostic sign you are looking for, and describe the additional sign that would indicate an actual volvulus. Explain why the plain film cannot be reassuring. (2 marks) ^[2]

d) The baby becomes increasingly lethargic with abdominal tenderness and passes blood per rectum. Describe the definitive operation and its steps, and state in which direction the volvulus is detorsed and why. (2 marks) ^[6]