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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