MIDGUT VOLVULUS - AN EVER-PRESENT THREAT

Objective: To identify risk factors for midgut volvulus (MGV) and to s eek clues to early diagnosis of MGV in children with malrotation. Desi gn: Retrospective patient series. Setting: Academic medical center. Pa tients: Sixty-eight consecutive children who had a Ladd operation perf ormed between January 1970 and December 1991. Excluded were three pati ents whose records were unavailable and patients who had a Ladd operat ion during the course of repair of an abdominal wall defect or congeni tal diaphragmatic hernia. Results: Forty of 68 patients had MGV at ope ration. There was an inverse correlation between age at onset of sympt oms and the probability of MGV: 85% (29/34) of patients less than 1 mo nth of age had MGV compared with 43% (10/23) of older children. Patien ts who had symptoms for less than 4 days were more likely to have MGV (88%; 30/34) than patients who had more chronic symptoms (43%; 10/23). Bilious (green) vomiting was more highly associated with MGV (80%; 35 /44) than nonbilious vomiting (38%; 3/8) or pain (50%; 6/12). Roentgen ograms of the upper gastrointestinal tract were very accurate for the diagnosis of malrotation but frequently failed to identify MGV (sensit ivity, 54%; 13/24). Despite the high proportion of MGV, only three pat ients had gangrenous bowel. Of these three patients, one died and two have short-gut syndrome. Conclusion: Neonates with a short history of bilious vomiting are most likely to have MGV-complicating malrotation, but older children who have chronic intermittent symptoms are also at risk. Since there is no way to predict which patients will develop ca tastrophic bowel necrosis, early diagnosis and operation are necessary to prevent mortality and short-gut syndrome.