ACUTE MIDGUT VOLVULUS CASE PRESENTATION

A CASE OF ACUTE MIDGUT VOLVULUS

Objectives

To present a neonate who was admitted for jaundice and vomiting

present the patient’s history, physical findings and the course of treatment done to the patient.

discuss the epidemiology, pathophysiology, clinical manifestation, diagnostic procedures, medical

and surgical treatment as well as the complications of midgut volvulus.

The Case

B.C.O., a 13 day old male neonate was admitted last Jan 3 2007 at CVGH for vomiting and Jaundice.

Prenatal History

3 months AOG Mother: 18 y.o, G1P0 Mother attempted to terminate

pregnancy -10 tabs of misoprostol no abdominal pain no vaginal bleeding

Prenatal Hx First PNC : 4 mos. AOG at a local

healthcenter prescribed : Multivitamins, Anmum milk

two shots of tetanus toxoid. Labs were CBC and urinalysis

(unremarkable) Mother neither smoke nor drinks

alcoholic beverages.

Natal Hx

born full term via NSD at CCMC with BW of 3.5 kgs AGA

had good cry and good suck prolonged labor of 20 hours no meconium staining no cord coiling

Postnatal Hx

@ 33 hrs old - had deep jaundice down to legs

was put on phototherapy for only 11 hrs bec family went HAMA

Persistent jaundice was noted at home

no medical consult done

Postnatal Hx

purely breastfed until present. Developmental milestone includes

preferential gaze to human face at present.

No known FDA nor HFD Mother’s blood type is AB+

HPI- Jaundice and Vomiting

since 33 hours old- (+) jaundice (+) good suck Bowel movement: 2-3x a day with

yellowish stools non bloody.

HPI- Jaundice and Vomiting

Hours PTA (13 days old) - had projectile vomiting :

½ -1 cup/ episode x >10 episodes (+) good suck (-) changes in urinary nor bowel

habits. (-) abdominal distention

PE

Examined an awake, active, comfortable, afebrile NIRD

Vital signs: HR-134bpm RR-36cpm T- 37.1

Wt- 3.5 kgs Ht- 50cm HC- 36cm CC- 36 cm AG- 37 cm

PE

Skin: warm scaly dry, skin pinch goes back slowly, jaundiced from face down to legs

HEENT- icteric sclerae, PPC, no NAD, no TPC, not sunken eyeball, moist lips and tongue, icteric buccal mucosa

C/L: ECE, CBS, no rales no wheeze

PE

CVS: AP, DHS, NRRR, no masses no organomegaly

Abd: globular, not distended, NABS, soft, no organomegaly, no mass

GUT: grossly male with descended testes, (+) diaper rash

EXT: strong peripheral pulses CRT <2sec, no limping

CNS: WNL

Impression

Sepsis Neonatorum

CIW – on Admission

HGT taken was 162 mg/dl

-thus venoclysis was started @ 75 cc/k/D @ D7.5

CIW-On Admission

Labs taken:1. CBC : WBC-14.4 ( N-62.9, L-19.4 M-15.7, E-0.2, B-

1.85) RBC 4.06 HGb-13.4 Hct- 38.7 PLT-525

CIW – on Admission

Labs taken:

2. serum Na-136mmol/L3. serum K-5.1 mmol/L 4. Blood Culture – no growth after 5

days5. Retic count-1.8%N

CIW-On admission

Labs taken:6. Peripheral Smear: normocytic, normochromic RBC no significant anisocytosis and poikilocytosis WBC and Platelets were

unremarkable

CIW-On admission

Labs taken:7. TBDB : TB-20.10 mg/dl DB-0.69mg/dl (@ photo level)-phototherapy started-Ampicillin (AD: 85.7 mkD) and

Amikacin (AD: 11.42 mkD) started

CIW

7 hours after admission:

OGT - bilious drainage of 15 ml. No abdominal distention noted.

CIW

7 hrs after admission: ABG: Ph – 7.465 pCO2 – 23.4 mmHg pO2 - 89.8 mmHg

HCO3 – 16.6 mmol/L ABE - -5.4 mmol/L SAT O2- 97.3 %

CIW

7 hrs after admission:UA- color: yellow appearance: hazy ph- 6 sp. Gravity: 1.022 protein: trace glucose: (-) RBC: (-) Red. Subst: (-) WBC: 0-1 E.C.: (-)

CIW

7 hrs after admission

Abdominal flat plate: triple bubble sign suggestive of duodenojejunal obstruction

Referred to Dept of Surgery for consult

Triple Bubble sign

CIW

9 hrs after admission: DRE : fresh bloody stools amounting

to 30-50 ml scheduled for STAT explore Lap with

the impression of possible midgut volvulus with malrotation

Fresh bloody stools

CIW – on Admission

14 hours after admission: pt operated with Ladd’s Procedure. Intraop findings: Midgut Volvulos

with malrotation with viable intestines and colon and no ischemia

With necrosis

CIW

Post-op orders: Ampicillin & Amikacin cont Phototherapy cont Parenteral feeding

CIW – 1st hospital day

(+) persistent moderate grade fever (37.7 C-38.5 C)

2x bilious vomitus - 5 ml each 1x of stool - yellowish non-bloody OGT drainage - 44 cc

CIW – 1st hospital day

HR-140-160, RR-40-68, UO 352 in 24 hrs.

still had deep jaundice down to legs. No abdominal distention. Surgical site was closely apposed

with no signs of infection Medication and Phototherapy

continued

CIW – 2nd hospital day

Abd: hypoactive bowel sounds no abdominal distention Surgical wound: closely apposed with

no infection. Stools : yellowish and non-blood

streak

CIW – 2nd hospital day

Bleaching of jaundice was noted TBDB: TB-18.06 mg/dl DB - 1.5 mg/dl IB-16.56 mg/dl phototherapy continued

CIW – 3rd hospital day

dropper feeding with EBM at 5 cc every 3 hours was started and tolerated

OGT was removed and feeding was gradually increased until patient was breastfed.

CIW – 5th-6th hospital day

phototherapy was discontinued patient was discharged on the 6th

hospital day after completing 7 days of Ampicillin and Amikacin with no rebound jaundice.

Final Diagnosis

Acute Midgut Volvulus with Malrotations/p Ladd’s Procedure

Discussion

Volvulus : complete twisting of a loop of intestine around its mesenteric attachment site.

sites: stomach, small intestine, cecum, transverse colon, and sigmoid colon.

Midgut volvulus: twisting of the entire midgut about the axis of the superior mesenteric artery

Pathophysiology

Embryologic devt of gut:

-at 4th-12th wk- EXTRACOELOMIC ELONGATION

Pathophysiology

After elongation:1. 270 counterclockwise rotation ofduodenum

Pathophysiology

After elongation:2. Cecocolic loopbegins to rotatebelow SMA

Pathophysiology

malrotation results from an interruption in intestinal rotation during the second stage of development.

In malrotation:1. the duodenal loop lacks 90° of its

normal 270° rotation2. the cecocolic loop lacks 180° of its

normal rotation.

Pathophysiology

Prenatal history: (+) intake of abortive substance

approximately on the 12th week of gestation

Epidemiology

In the US: An incidence of 1 in 500 live births has been reported

Sex: No sex predilection exists; however, midgut volvulus predominates in male infants, with a male-to-female ratio of 2:1 in the neonatal period.

Epidemiology

Age: 68-71% are neonates. Most cases occur by age 2 months, but up to 41% of cases occur at an older age.

Index case was still a neonate particularly 13 days old who presented symptoms within first to second week after birth.

Clinical Manifestation

40% of infants develop sx within the first week after birth,

50% present within the first month, 75% present before age 1 year, and the remaining 25% present after

age 1 year.

Clinical Manifestation

Hallmark: Bilious Vomiting (77-100%)

most typical presentation:1. feeding intolerance 2. bilious vomiting and 3. sudden onset of abdominal pain

Initial presentation of patient: jaundice, bilious vomiting, bloody stools

Clinical Manifestation In early cases, patients may appear

well with normal abdominal findings 50% - Abnormal abdominal findings 32% - of had abdominal distension

but no tenderness. obstruction is very proximal:

abdominal distension is not usually present.

Patient had no abdominal distention

Clinical Manifestation

may reveal a palpable abdominal mass in some patients.

Signs of intraluminal blood loss, such as hematochezia or stool guaiac testing, are usually positive.

Pt had no abdominal mass(+) fresh bloody stools

Clinical Manifestation

Once ischemia occurs, almost all patients develop diffuse and severe abdominal pain and signs of peritonitis

Patients with gangrene are usually tachycardic and hypovolemic

Clinical Manifestation

Passage of blood or sloughed mucosal tissue may be noted as vascular compromise progresses.

As ischemia progresses to infarction and necrosis, fever, peritonitis, abdominal distension, profound hypovolemia, and septic shock develop

Clinical Manifestation

Atypical Presentation of Midgut Volvulos: 1. projectile non-bilous emesis2. colicky abdominal pain with suspicion

of intussusception3. palpable abdominal mass4. right lower quadrant abdominal pain

with suspected appendicitis,

Journal of Ultrasound Medicine. 2004 March; 23 (3): 397-401

Clinical Manifestation

Atypical presentation (cont…)5. chronic diarrhea6. epigastric lumps7. vague abdominal pain 8. weight loss.

Journal of Ultrasound Medicine. 2004 March; 23 (3): 397-401

Lab Studies

hemogram, clotting studies, electrolyte level tests, and blood glucose level tests are usually sufficient for preoperative evaluation

Labs taken in patient:1. CBC 5. Peripheral smear2. Serum Na,K 6. Retic Count3. ABG 7. TBDB4. Blood Culture 8. HGT

Imaging Studies

Flat, upright, and cross-table lateral radiographs of the abdomen may show :

1. small bowel obstruction2. dilated small-bowel loops3. marked gastric or proximal duodenal

dilatation, with or without intestinal gas4. air-fluid levels

Only flat upright was taken on the patient

Imaging Studies

Upper gastrointestinal imaging The corkscrew sign:

Imaging Studies

The corkscrew sign: (spiral sign)-a spiral configuration of the fourth

portion of the duodenum and the proximal jejunum visualized in midgut volvulus.

-seen in frontal and lateral images from a contrast material–enhanced upper gastrointestinal (GI) examination of pediatric patients, esp. < 1 year

Imaging Studies

Upper GI findings in malrotation with midgut volvulus:

dilated, fluid-filled duodenum   proximal small bowel obstruction   "corkscrew" pattern Mural edema and thick folds

Imaging Studies

Ultrasonography: Whirlpool Sign:

Imaging Studies

Whirlpool Sign:This swirling, whirlpool-like shape is

created when the superior mesenteric vein (SMV) and the mesentery wrap around the superior mesenteric artery (SMA) in a clockwise direction which indicates midgut volvulus.

Visualization is enhanced by the vascular signal at color Doppler flow US

Imaging Studies

Ultrasonography: Whirlpool Sign:

Swirling whirlpool shape Vascular flow via doppler

An objective and definite sign of Midgut volvulus is a clockwise whirlpool sign at Color Doppler Ultrasound which gives a 92% sensitivity and 100% specificity.

Radiology 1996 Apr; 199 : 261-4. Shimanhi et, al.

Ultrasound is a good screening test for Intestinal malrotation by showing abdominal orientation of SMA and SMV.

Pediatric Surgery. 2006 May; 41(5) : 1005-9

Differentials

1. Hirschprung Disease Hirschsprung disease results from the

absence of parasympathetic ganglion cells in the myenteric and submucosal plexus of the rectum and/or colon.

may present with abdominal distention, failure of passage of meconium within the first 48 hours of life, and repeated vomiting.

Index case did not present with abdominal distention but history of delay of passage of meconium can

not be revealed, but presented with vomiting

Differentials2. Duodenal Atresia Duodenal atresia represents complete

obliteration of the duodenal lumen. investigation.

Bile-stained vomit in neonates aged 24 hours or younger is the typical presentation

vomit is free of bile if atresia is proximal to ampulla of Vater

index case presented with bilous vomitus and abdominal xray also showed bubble signs

Differentials3. Cholecystitis/Cholelithiasis The classic history of patients with

gallstones is postprandial right upper quadrant pain associated with nausea and vomiting, but this is usually observed only in older children.

This combination of right upper quadrant pain, fever, and jaundice is indicative of obstruction to the common bile duct The index case had jaundice from delivery up

to present but no febrile episodes noted and abdominal pain can not be elicited

Differentials

4. Intussusception Intussusception is a process in which a

segment of intestine invaginates into the adjoining intestinal lumen, causing a bowel obstruction.

The patient is usually an infant who presents with vomiting, abdominal pain, passage of blood and mucus, lethargy, and a palpable abdominal mass.

index case had vomiting and passage of blood per rectum however no abdominal mass

nor abdominal distention noted

Treatment

Medical Care: carry out aggressive crystalloid fluid

resuscitation Place a nasogastric tube for luminal

decompression

Parenteral feeding was given to the patientand OGT was placed

Treatment

Surgical Care: Ladd’s Procedure (“turn back the hands against

time”)1. division of mesenteric bands 2. placement of the small intestine on the

right and the colon on the left side of the abdomen

3. appendectomy Appendectomy was not done to the patient

Treatment

Surgical Care:-Intra-operatively findings of viable

intestines was noted

Doppler probe or fluorescein with a Wood light may be helpful in documenting the

viability of the bowel

Treatment

a second-look procedure 24 hours later for pts with questionable viability

When bowel appears necrotic, the surgeon decides to either close or resect the bowel

Treatment

Broad-spectrum antibiotics: 1. ampicillin 2. clindamycin, and 3. gentamicin or cefotetan

Complications

Midgut volvulus carries a mortality rate of 3-15%.

If resection of bowel is done: Short gut syndrome long-term parenteral nutrition line sepsis growth retardation and hepatobiliary dysfunction

Complications

Long term complications following intestinal malrotation and Ladds:

study showed 54% had no complication after Ladds

while 46% had complications

Pediatric Surgery 2006 Apr; 22(4): 326-9. Epub et, al.

Complications

Those with complications:

1. 9% of them had feeding difficulties2. 2% had chronic abdominal pain3. 26% required readmission within first 6

months4. 24% were readmitted with acute bowel

manifestation5. 13% required multiple admission6. 13% underwent further surgery due to

adhesion related surgery. Pediatric Surgery 2006 Apr; 22(4): 326-9. Epub et, al.

Conclusion

The case clinically presented a newborn with bowel obstruction. With prompt surgical intervention patient was saved with long term complication of short gut syndrome.

However, we should still be watchful of possible bad outcomes from the procedure, thus proper follow-up care should be observed

Thank You