Case # 2: Midgut volvulus
A 4-year-old male presented with sudden, constant, and intense abdominal pain that woke him from sleep. He previously had been healthy, without any changes in bowel habits, nausea, or vomiting. Vital signs were within normal limits for age. On physical exam the child had a slightly distended abdomen and was writhing in pain. The patient received intravenous (IV) fluids and morphine. Labs were noncontributory except for a white blood cell count of 28,000. Plain films revealed evidence of a small-bowel obstruction, and midgut volvulus was confirmed on upper-gastrointestinal (GI) series. The patient was emergently taken to the operating room. Recovery was uneventful.
Midgut volvulus is a potentially life-threatening cause of abdominal pain in young children, most often occurring in neonates and 75% of all cases occurring within the first year of life.6 It is caused by small-bowel malrotation, which results from incomplete or deviated rotation of the bowel during embryologic development.7 This leads to obstruction and ischemia.
The typical presentation in neonates is bilious emesis, and in this age group, this presentation must be considered a malrotation with midgut volvulus until proven otherwise. Older children tend to present with more chronic complaints of intermittent vomiting, diarrhea, and vague abdominal pain. These nonspecific symptoms often lead to multiple visits to the emergency department for acute management and to the pediatrician and gastroenterologist for malnourishment.
The diagnostic test of choice for identifying volvulus is an upper-GI series (Figure 3), which may show the classic “corkscrew sign.”8 Other useful tests include abdominal x-ray or US, which may show findings suggestive of small bowel obstruction or malrotation, respectively, as well as serum lactic acid level to show ischemia. However, diagnosis must be made quickly, because delay in getting to surgery may result in bowel necrosis, sepsis, and death.
Figure 3. High bowel obstruction with dilated loops of proximal bowel can be seen in midgut volvulus in a 4-year-old boy.
Midgut volvulus is a true pediatric surgical emergency and is normally corrected using Ladd procedure, which consists of correctional placement of the cecum and colon while widening the mesentery of the small intestine.
Case # 3: Ovarian torsion
A 4-year-old female presented to our hospital with sudden, severe, and constant abdominal pain located in the right lower quadrant that woke her from sleep. She had been healthy previously, with no prior complaints of nausea, vomiting, dysuria, or changes in bowel habits. Her vital signs were within normal limits for age, and physical exam was benign other than moderate tenderness at McBurney’s point without rebound, rigidity, or guarding.
All laboratory tests were unremarkable. Abdominal and pelvic computed tomography (CT) with contrast revealed a noncommunicating cystic mass abutting the left dome of the bladder, measuring 5.0 x 4.2 x 4.8 cm. This was also demonstrated by US. The child was subsequently taken to the operating room, where surgical exploration revealed a right ovarian cyst with torsion.9
Ovarian torsion can occur in females of all ages, but it is rare in the younger population—a fact that often leads to a delay in diagnosis. In adolescents and adults, ovarian torsion is more likely to be associated with an ovarian cyst, but in younger girls, the ovaries are often normal.
Ovarian torsion can cause compression of the vessels in the suspensory ligament, impeding blood flow and potentially leading to ischemia, necrosis, infarction, or hemorrhage. Children with ovarian torsion may present with acute lower abdominal pain, intermittent nausea and vomiting, and, sometimes, fever.
Pain can be either constant or colicky, depending on whether the ovary goes in and out of torsion or if it remains in the state once torsion occurs. In prepubescent girls especially, ovarian torsion can easily be mistaken for appendicitis because the pain often occurs in the area of McBurney’s point, with one key difference being that pain in appendicitis is often migrating, whereas the typical pain in ovarian torsion is not.10
The test of choice for diagnosis of ovarian torsion is US with Doppler, which can demonstrate cysts or masses as well as lack of blood flow. Although not always visualized, lack of flow to the ovary is pathognomonic for torsion.11 Treatment is surgical and with as little delay as possible to attempt to salvage the ovary.