Bilious Vomiting in a 5-Week-Old: Malrotation With Volvulus
A 5-week-old girl, born at 36 weeks, presents with 2 days of vomiting that has become bilious, lethargy, and decreased wet diapers. Heart rate is 180/min, blood pressure 70/40 mmHg, capillary refill 4 seconds, and temperature 36.8°C. The abdomen is mildly distended and tender without rigidity, and there is no pneumoperitoneum on plain radiograph. Ultrasound shows a whirlpool sign and dilated proximal bowel. Venous blood gas: pH 7.22, bicarbonate 14 mEq/L, lactate 3.8 mmol/L. Sodium is 132 mEq/L, potassium 3.2 mEq/L, chloride 98 mEq/L, and glucose 58 mg/dL. The surgical resident is preparing the operating room while the emergency department asks whether the child is stable enough for CT and whether antibiotics should be given before surgery.
1. Is this child stable enough for CT? What immediate resuscitation and preparation are required?
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No. This infant is in compensated or decompensating shock with tachycardia, delayed capillary refill, hypotension, metabolic acidosis, and lactic acidosis. She should not go to CT. The ultrasound already shows a whirlpool sign consistent with malrotation and volvulus, and the diagnosis is a surgical emergency.
Immediate steps:
- Obtain intravenous or intraosseous access and begin isotonic fluid boluses of 10 to 20 mL/kg, reassessing heart rate, perfusion, and lung sounds after each bolus.
- Place a nasogastric tube for decompression to reduce aspiration and bowel distension.
- Check and correct glucose; give dextrose for hypoglycemia. Correct potassium only after adequate urine output is established.
- Start broad-spectrum antibiotics covering enteric organisms because ischemic bowel is likely; do not delay surgery for cultures.
- Type and crossmatch blood, keep the infant warm, and involve anesthesia and neonatology.
Why not CT: The diagnosis is already supported, the child is unstable, and the time required for transport and scanning risks bowel necrosis. The correct next step is urgent laparotomy after initial resuscitation, not further imaging.
2. What is the operative strategy, and how do you decide between resection with anastomosis and resection with a stoma if bowel is necrotic?
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The operation is a Ladd procedure with detorsion. Enter through a transverse upper abdominal incision, eviscerate the bowel, and detorse the volvulus in a counterclockwise direction. Assess viability after detorsion with warm packs and observation for 10 to 15 minutes, checking color, peristalsis, and Doppler flow.
If bowel is viable: Divide the Ladd bands, widen the mesenteric base, place the small bowel on the right and the colon on the left, and perform appendectomy to prevent future diagnostic confusion. Do not attempt to restore normal rotation.
If bowel is necrotic: Resect clearly dead bowel. The choice between primary anastomosis and stoma depends on the extent of resection, the infant's stability, contamination, and the condition of the remaining bowel. In an unstable, acidotic infant with questionable viability at the margins, a stoma is safer. If the resection is limited and the child is stable with healthy margins, primary anastomosis is reasonable. A second-look operation is appropriate when viability is uncertain.
Avoid extensive resection of marginal bowel without a planned second look, because short bowel syndrome is a lifelong consequence.
3. What postoperative problems do you anticipate, and what would you tell the family?
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Early problems:
- Prolonged ileus and need for nasogastric decompression and parenteral nutrition.
- Sepsis, wound infection, and anastomotic leak if a resection was performed.
- Short bowel syndrome if a large segment was resected; this affects growth, nutrition, and long-term venous access.
- Adhesive small bowel obstruction, which can occur years later.
Late problems:
- Recurrent volvulus is uncommon after an adequate Ladd procedure, but adhesions are a real risk.
- If a stoma was created, the family must learn stoma care and understand the plan for closure.
Counseling: Explain that the immediate operation was needed to save bowel and that the child will need close follow-up for growth and nutrition. Give clear return precautions for bilious vomiting, abdominal distension, fever, or decreased feeding. Avoid promising a normal course; the outcome depends on how much bowel was viable. Document the discussion and provide written information in the family's language.