Malrotation and volvulus

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]

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1. [1]Godbole P; Stringer MD Bilious vomiting in the newborn: How often is it pathologic? J Pediatr Surg, 2002.PMID 12037761
2. [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. [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
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9. [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. [10]Johnston WR; Hwang R; Mattei P Laparoscopic Versus Open Ladd Procedure for Midgut Malrotation. J Pediatr Surg, 2024.PMID 39209687
11. [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. [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