BG was a 35 week preemie via C/S to a 23–year–oldo G2P1 mom due to preterm labor. Pregnancy was complicated by a progressively dilated loop of bowel without haustrations and only very occasional peristalsis seen on prenatal sonograms from 34 weeks AOG. At delivery BG had a firm distended stomach. An OG tube drained 3 ml of yellowish fluid. A KUB taken immediately showed no air past the pylorus. BG immediately underwent emergency exploratory laparotomy. A 15 cm segment of necrotic and hemorrhagic mid–ileum was resected, both the proximal and distal bowel appeared normal. There was no evidence of malrotation, rather a short segment of small bowel with its’ attached mesentery had volved upon itself. An end to end re–anastomosis was done. BG tolerated the procedure well, was on TPN for 7 days, and gradually started on feeds. BG was discharged after 4 weeks and has been seen at the Pediatric Clinic, thriving and developmentally up to date.
Midgut volvulus is a surgical emergency largely encountered in the neonatal period and is usually associated with intestinal malrotation. Conversely, midgut volvulus without malrotation is an extremely rare cause of acute intestinal obstruction in the neonatal period. This condition has a high morbidity and mortality and its’ exact etiology and pathogenetic mechanisms are unknown. A primary intestinal defect has been proposed as a possible cause. Midgut volvulus occurring prenatally is also rare. Presenting features may include ultrasonographic signs of fetal intestinal obstruction and perforation (polyhydramnios, intestinal dilatation, an abdominal mass) and signs of fetal distress. The whirlpool sign is the definitive sonographic sign of midgut volvulus due to malrotation, but the prenatal detection of the whirlpool sign is quite difficult and few cases have been reported. After birth, a tense and distended abdomen, an abdominal mass, dark discoloration of the abdominal wall (Cullen’s sign), bile emesis or aspirate, failure to pass meconium,or bloody diarrhea with shock are the symptoms suggestive of volvulus. The outcome of in utero intestinal volvulus depends on the amount of intestine that is compromised by the volvulus and the gestational age at the time of the event. High morbidity and mortality associated with fetal midgut volvulus is due in part to late diagnosis, which may lead to extensive ischemic necrosis of the bowel.
Midgut volvulus without malrotation is an extremely rare cause of acute intestinal obstruction in the neonatal period. Midgut volvulus occurring prenatally is also quite rare and the prenatal diagnosis of midgut volvulus is difficult. The outcome depends on the amount of intestine that is compromised by the volvulus. Close prenatal monitoring and appropriate timing of delivery in cases where ultrasound examination shows signs of fetal intestinal obstruction, as well as optimal postnatal treatment are all essential to reduce the morbidity and mortality associated with intrauterine midgut volvulus.
Percentage discharge order by 11 AM by physician.