Paeds · gastroenterology-hepatology-and-nutrition
Malrotation and volvulus
Also known as Intestinal malrotation · Midgut volvulus · Rotational abnormality · Ladd bands · Ladd procedure · Non-rotation · Corkscrew sign · Whirlpool sign · Duodenojejunal flexure · Short gut syndrome from volvulus · Intermittent volvulus
Fellowship guide to intestinal malrotation and midgut volvulus, the one rotational anomaly that turns a well neonate into a surgical catastrophe within hours. The page follows the embryology that builds the narrow mesenteric stalk, the bilious vomiting that demands an upper gastrointestinal contrast study, the whirlpool and corkscrew signs, and the Ladd procedure that untwists the volvulus, divides the bands and widens the base so the midgut cannot twist again.
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Target exams
Red flags
- Sudden bilious vomiting in a previously well neonate is midgut volvulus on a malrotation until proven otherwise and earns resuscitation, nasogastric decompression and an emergency surgical opinion the same hour, not the next day
- A well-looking neonate with bilious vomiting can still have a volvulus strangulating the entire midgut, because tenderness, distension and shock are late signs that appear once the bowel is already dying
- An older child or adolescent with recurrent bilious vomiting, intermittent central abdominal pain and faltering growth can harbour an intermittent volvulus on a missed malrotation and deserves an upper gastrointestinal contrast study
- Blood in the stool, a tender rigid abdomen, abdominal wall discolouration or cardiovascular collapse in a child with bilious vomiting signals bowel ischaemia or perforation and a move straight to theatre without waiting for imaging
- A normal plain abdominal radiograph never excludes malrotation or volvulus, so it must never be used as reassurance against the diagnosis
Life stages
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- Recognition of bilious vomiting as a surgical emergency
- Embryology of normal gut rotation and how malrotation predisposes to volvulus
- Resuscitation of the neonate with suspected midgut volvulus
- Malrotation and midgut volvulus: diagnosis and the Ladd procedure
- Upper gastrointestinal contrast study and the whirlpool sign
- Management of asymptomatic and incidentally found malrotation
- The neonate with bilious vomiting and suspected volvulus
- Interpreting the upper gastrointestinal contrast study
- Fluid and electrolyte management of the obstructed child
- Long case: the child with short gut syndrome after midgut volvulus
- Short case: the acute surgical abdomen in the neonate
- Neonatal surgery: malrotation and midgut volvulus
- Acute surgical abdomen in the child
- Malrotation, volvulus and the Ladd procedure
- Upper gastrointestinal contrast signs of malrotation and volvulus
- Assessment of the infant with bilious vomiting
- Malrotation and midgut volvulus
- Bilious emesis in the newborn
- The Ladd procedure
- Patient Care: recognition and stabilisation of the surgical abdomen in children
- Medical Expert: malrotation and midgut volvulus in children
Overview & Definition
Picture a three-day-old baby who fed and stooled normally, then suddenly vomits a mouthful of bright green fluid. That single colour changes everything, because in a neonate it points first and fastest to malrotation with midgut volvulus, the one condition that can strangle the entire small bowel within hours. Bile is green because it enters the gut beyond the ampulla of Vater, so green vomit places the obstruction at or below the second part of the duodenum, and the diagnosis you must exclude before any other is a midgut that is twisting on an abnormally narrow mesenteric stalk. [1] [2]
Intestinal malrotation is an abnormality of the gut's embryological rotation and fixation in which the bowel is not anchored on the broad, stable mesenteric base that normally holds it. The midgut, which runs from the distal duodenum to the proximal two-thirds of the transverse colon and is supplied by the superior mesenteric artery, normally settles with the duodenojejunal flexure fixed high on the left and the caecum fixed low on the right, creating a wide diagonal base that cannot twist. When rotation is incomplete the base stays short and narrow, the midgut dangles from a pedicle around the artery, and a clockwise twist of that pedicle is a midgut volvulus. [2] [8]
The task in the emergency is therefore to act on the pattern of bilious vomiting, not to wait for proof of the anatomy. You keep the child nil by mouth, decompress the stomach, resuscitate and involve a surgeon at once, because the cost of treating a benign cause as an emergency is small while the cost of missing a volvulus is the loss of the entire midgut. Most neonates with bilious vomiting turn out to have something less dangerous, yet every episode earns the same urgent respect, and a normal plain film never closes the question. [1] [3]
References12ShowHide
- [1]Godbole P; Stringer MD Bilious vomiting in the newborn: How often is it pathologic? J Pediatr Surg, 2002.PMID 12037761
- [2]Lampl B; Levin TL; Berdon WE; Cowles RA Malrotation and midgut volvulus: a historical review and current controversies in diagnosis and management. Pediatr Radiol, 2009.PMID 19241073
- [3]Salehi Karlslätt K; Husberg B; Ullberg U; Nordenskjöld A Intestinal Malrotation in Children: Clinical Presentation and Outcomes. Eur J Pediatr Surg, 2024.PMID 36882104
- [4]Graziano K; Islam S; Dasgupta R; Lopez ME Asymptomatic malrotation: Diagnosis and surgical management: An American Pediatric Surgical Association outcomes and evidence based practice committee systematic review. J Pediatr Surg, 2015.PMID 26205079
- [5]Dekonenko C; Sujka JA; Weaver K; Sharp SW The identification and treatment of intestinal malrotation in older children. Pediatr Surg Int, 2019.PMID 30810798
- [6]Ingoe R; Lange P The Ladd's procedure for correction of intestinal malrotation with volvulus in children. AORN J, 2007.PMID 17292689
- [7]Choi G; Je BK; Kim YJ Gastrointestinal Emergency in Neonates and Infants: A Pictorial Essay. Korean J Radiol, 2022.PMID 34983099
- [8]Svetanoff WJ; Srivatsa S; Diefenbach K; Nwomeh BC Diagnosis and management of intestinal rotational abnormalities with or without volvulus in the pediatric population. Semin Pediatr Surg, 2022.PMID 35305800
- [9]Collins GL; Hargis-Villanueva AE; Jayaraman MS; Lai K A Prospective Management Strategy for Heterotaxy Syndrome with Intestinal Rotation Abnormalities: Imaging Does Not Predict Need for Surgery. J Pediatr Surg, 2023.PMID 36740478
- [10]Johnston WR; Hwang R; Mattei P Laparoscopic Versus Open Ladd Procedure for Midgut Malrotation. J Pediatr Surg, 2024.PMID 39209687
- [11]Zhang W; Sun H; Luo F The efficiency of sonography in diagnosing volvulus in neonates with suspected intestinal malrotation. Medicine, 2017.PMID 29049228
- [12]Sabac D; Briatico D; Fitzgerald P Assessment of care timelines in intestinal malrotation with volvulus: A retrospective chart review. J Pediatr Surg, 2023.PMID 36805138