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Midgut Volvulus


KEY FACTS

Terminology

  • Ligament of Treitz: Suspends duodenojejunal junction (DJJ), defines normal duodenal rotation

  • Malrotation: Abnormal rotation & fixation of small bowel (SB) mesentery that can lead to complications

    • Bowel obstruction by Ladd bands

    • Midgut volvulus (MV) due to short mesenteric base, prone to twisting

  • MV: Twisting of SB about superior mesenteric artery → bowel obstruction, ischemia/necrosis

Imaging

  • Radiographs: Most common appearance is normal

    • Distended stomach & proximal duodenum with ↓ distal bowel gas very suggestive

    • May rarely show diffuse distal bowel distention/ileus from ischemia/necrosis

  • Upper GI: Dilated duodenum to D2-D3 segment with corkscrew/spiral sign just beyond duodenal “beak”

  • US or CT: Whirlpool sign

Top Differential Diagnoses

  • Malrotation with obstructing Ladd band

  • Spectrum of congenital duodenal obstructions

Pathology

  • If bowel malrotated, DJJ-cecal distance (mesenteric base) is short, predisposing to twisting (volvulus)

Clinical Issues

  • Classic presentation: Infant with bilious vomiting

    • > 90% present within first 3 months of life

    • Requires emergent upper GI (best imaging tool)

  • Delayed diagnosis can lead to diffuse bowel necrosis

  • Treatment: Surgical emergency (Ladd procedure)

    • Reduce volvulus, resect nonviable bowel, transect Ladd bands (if present), place SB in right & colon in left abdomen

Anterior graphic shows a midgut volvulus (MV) with dilation of the proximal duodenum
that tapers into a coil of twisted, narrowed loops
. The cecum
is malpositioned within the right upper quadrant medially & fixed by a Ladd band
. Note the purple discoloration & dilation of the remaining small bowel due to an ischemic ileus.

AP radiograph shows a nonobstructive bowel gas pattern in a patient with bilious emesis who was ultimately found to have MV on a subsequent upper GI series.

Lateral upper GI in a 3-day-old boy with bilious vomiting shows a dilated duodenum
up to D3, which ends in a beak-like configuration
with a wisp of contrast
extending distally, highly suggestive of MV.

Frontal upper GI image in the same patient (a few seconds later) shows proximal duodenal dilation
with partial obstruction at D3
. The corkscrew/spiral sign
is diagnostic of MV. Thickened loops
in this context suggest bowel ischemia.

TERMINOLOGY

Definitions

  • Ligament of Treitz: Suspends duodenojejunal junction (DJJ), defines normal duodenal rotation

  • Malrotation: Abnormal rotation & fixation of small bowel (SB) mesentery that can lead to complications

    • Bowel obstruction by Ladd (peritoneal) bands

    • Midgut volvulus (MV) due to short mesenteric base prone to twisting

  • MV: Abnormal twisting of SB about superior mesenteric artery (SMA) that can lead to bowel obstruction & ischemia/necrosis

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