Diagnosis

Abstract

Malrotation with midgut volvulus. Radiographs revealed a right-sided stomach bubble (open arrow) with a paucity of small bowel gas in the left midabdomen (closed arrow), suggestive of situs inversus and proximal small bowel obstruction (Figures 1 and 2). Upper gastrointestinal contrast study revealed focal high-grade narrowing of the descending duodenum. The child underwent exploratory laparotomy and was found to have complete situs inversus with malrotation and duodenal obstruction. Her postoperative course was uncomplicated, and she was dismissed on hospital day 5. Bilious vomiting in a neonate is malrotation until proven otherwise. Associated volvulus occurs in 68% to 71% of cases. Other differential diagnostic considerations include incarcerated hernia and duodenal atresia. Initial evaluation should include flat and upright radiographs of the abdomen, followed by upper gastrointestinal contrast study. Management of malrotation with volvulus requires aggressive fluid resuscitation, nasogastric tube placement, intravenous antibiotics, and early pediatric surgical consultation. Images in Emergency MedicineAnnals of Emergency MedicineVol. 46Issue 6PreviewA 4-day-old girl, born at 38 3/7 weeks gestation by emergency C-section for fetal bradycardia, presented to the emergency department for evaluation of vomiting since birth. Her postnatal course was otherwise unremarkable. The emesis was described as yellow-green and nonbloody. Vital signs included pulse of 136 beats/min, respiratory rate of 34 breaths/min, and temperature of 37.4°C (99.3°F). Physical examination revealed a well-hydrated, alert, and interactive child. The only notable finding was the presence of decreased bowel sounds. Full-Text PDF