The mother of a 3-week-old infant calls the office to report the following: Thirty minutes ago the infant started vomiting; it looks “grass green”; she cries if you touch her belly and is starting to get sleepy. You tell her to drive immediately to the emergency department: this is an emergency. You are worried about malrotation with volvulus.
A. After 1 year of age.
B. In the first month of life.
C. In adolescence.
D. Immediately after birth.
The correct answer is “B.” This infant has malrotation with volvulus—a surgical emergency. Rotational anomalies may become symptomatic at any age; however, more than 80% present in the first month of life, often in the first week. Risk of acute volvulus is highest in the neonatal period. In malrotation, the intestine fails to rotate in utero and fixate in the correct position. It is adhered by a narrow pedicle of mesentery, which allows the intestine to twist around itself. The cecum ends up in the right upper quadrant. The risk is volvulus, most often at midgut. This occurs when the intestine strangulates by twisting, cutting off the blood supply and blocking the flow of fecal contents and gas through the tract. Bad outcomes (perforation, infarction) ensue if it is not surgically corrected. (You may have heard the term Ladd bands used. These are tissue bands that cross and obstruct the duodenum). Any infant who presents with bilious emesis is an emergency case. There is also an atypical presentation. (Are you surprised?) Intermittent twisting with pain and vomiting may occur in older children. It is frequently misdiagnosed as cyclic vomiting.