Intended for healthcare professionals

Practice Easily Missed?

Intestinal malrotation and volvulus in infants and children

BMJ 2013; 347 doi: (Published 26 November 2013) Cite this as: BMJ 2013;347:f6949
  1. Mohamed Sameh Shalaby, senior clinical fellow in paediatric surgery,
  2. Kamal Kuti, paediatric surgery registrar,
  3. Gregor Walker, consultant paediatric surgeon
  1. 1Department of Paediatric Surgery, Royal Hospital for Sick Children, Glasgow, UK
  1. Correspondence to: M S Shalaby mshalaby{at}
  • Accepted 23 October 2013

The parents of a 2 week old term baby presented to the out of hours general practice service late in the evening with a two hour history of green vomiting. As the baby looked well, had been passing stools and urine normally, and had a soft non-tender abdomen, they were advised to attend their own general practice the following morning. The baby arrived in the local emergency department by ambulance six hours later with intractable shock. After aggressive resuscitation, the baby was taken to theatre for emergency laparotomy that revealed intestinal ischaemia from midgut volvulus associated with malrotation.

What is intestinal malrotation and volvulus?

Intestinal malrotation occurs because of failure of the normal sequence of rotation and fixation of the bowel (fig 1). Duodenal obstruction can occur due to extrinsic compression from bands leading from the caecum to the lateral abdominal wall (Ladd’s bands) or from small bowel volvulus, which also leads to ischaemia of the midgut from superior mesenteric artery occlusion (fig 2).1 Midgut volvulus can lead to irreversible intestinal necrosis, which is potentially fatal.1

Fig 1 Left: Diagram of normal intestinal rotation. The third part of the duodenum (a) should cross the midline, with the fourth part (b) ascending on the left of the midline to the same level as the pylorus. Shaded part of bowel represents the midgut that is exclusively supplied by the superior mesenteric artery (c). Right: Normal upper gastrointestinal contrast study

Fig 2 Left: Diagram of classic intestinal malrotation with abnormal duodenal fixation, Ladd’s bands crossing the duodenum (a), and narrow base of mesentery (b). Centre: Diagram of small bowel volvulus …

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