Midgut Volvulus

Aka: Midgut Volvulus, Small Bowel Volvulus, Duodenal Volvulus, Congenital Volvulus, Double Bubble Sign, Malrotation with Volvulus

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II. Definitions

  1. Volvulus
    1. Twisting of intestinal loop around attachment to mesentery
    2. Can occur at Stomach (Gastric Volvulus), Small Intestine, cecum, transverse colon or sigmoid colon
  2. Midgut Volvulus (Malrotation with Volvulus)
    1. Associated with Intestinal Malrotation
    2. Presents in infants in 90% of cases

III. Epidemiology

  1. Malrotation with Volvulus often presents in first few weeks of life (75% present in first month, 90% in first year)

IV. Symptoms: Midgut Volvulus (infants and children)

  1. Infants
    1. Bilious Emesis
    2. Sudden onset of Abdominal Pain
    3. May present with Failure to Thrive and "reflux"
  2. Older children
    1. Chronic intermittent Vomiting and abdominal cramping
    2. Failure to Thrive
    3. Constipation
    4. Bloody Diarrhea

V. Signs

  1. Abdominal exam may be benign
  2. Abdominal Distention is often a late finding in acute Volvulus
  3. Heme positive stool
    1. Late sign suggesting infarcted bowel

VI. Differential Diagnosis

  1. See Abdominal Pain Causes

VII. Imaging: Acute Midgut Volvulus (children)

  1. Upper GI Cotrast Study (preferred)
    1. Performed with Nasogastric Tube delivered contrast
    2. Realtime monitoring of contrast passage via fluoroscopy
    3. Corkscrew appearance of faint contrast line at point of malrotation
    4. If not available, emergent transfer to facility capable of Upper GI study if malrotation is suspected
  2. Abdominal XRay
    1. Often non-specific
    2. Dilated Stomach and proximal duodenum with intervening pylorus (Double Bubble Sign)
      1. Double-Bubble is also seen in Duodenal Atresia (typically diagnosed in newborn nursery)
    3. Paucity of gas distal to dilated duodenum/Stomach
  3. References
    1. Tubbs and Janicki (2025) Mastering Emergency Imaging, CCME, accessed 7/8/2026

VIII. Complications

  1. Intestinal infarction (high mortality, 3-15%)
  2. High morbidity related to Ischemic Bowel, resections resulting in short gut syndrome

IX. Management

  1. Acute stabilization
    1. ABC Management
    2. Fluid Resuscitation
    3. Correct Electrolyte abnormalities
    4. Broad spectrum Antibiotics for peritonitis
    5. Nasogastric Tube decompression
  2. Emergent surgical management
    1. Mesenteric Infarction and necrosis starts within first 3 hours of onset
    2. Necrotic bowel resected if needed
    3. Ladd Procedure reduces the Volvulus
      1. Bowel rotated counter-clockwise
      2. Mesenteric bands (Ladd Bands) are divided
      3. Small Bowel placed on the right side of Abdomen
      4. Large Bowel placed on the left side of Abdomen
      5. Appendectomy
      6. Widens mesenteric pedicle and reduces risk of Volvulus recurrence (but does not correct malrotation)

X. Resources

  1. Hebra (2012) Intestinal Volvulus, Medscape

XI. References

  1. Jones (2022) Crit Dec Emerg Med 36(2): 14-5
  2. Lampl (2012) Pediatr Radiol 39:359-66 [PubMed]
  3. Laurence (2012) Pediatr Emerg Care 28(1): 87-9 [PubMed]

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