Infants, who have developed volvulus due to intestinal malrotation, suffer from signs and symptoms similar to those of bowel obstruction. Symptoms tend to get so severe, that the infant needs immediate hospitalization. Affected infants present with the following signs and symptoms:

• Nausea accompanied by vomiting
• Constipation
• Passing blood or dark colored stools
• Vomiting up green colored bile like material
• Tenderness in the abdominal region
• Abdominal distention
• Shock 

In addition, affected individuals would also complain of recurrent attacks of abdominal pain accompanied by several vomiting bouts which tend to cease without treatment. Such symptoms are characteristic of condition known as intermittent volvulus; wherein the bowel suddenly twists giving rise to unpleasant symptoms and untwists by itself [7].

• Sepsis

  FBC helps to assess the severity of the illness; a raised white cell count may be found in sepsis or gangrene and a low haemoglobin may suggest venous oozing. [patient.info]

  Complications Complications of a volvulus can include sepsis; a severe blood infection. A volvulus must be treated as soon as possible to lessen the risk of complications. [medicalnewstoday.com]

  Physical exam findings are non-specific; peritoneal signs indicative of perforation that can lead to sepsis and shock are late signs and indicate a poor prognosis. [ahcmedia.com]

  […] analysis, Annals of Surgery, anomalies, anorectal malformation, appendicitis, appy, asymptomatic, bariatric emergencies, beak appearance, biliary atresia, bilious emesis, bowel injury, bowel ischemia, bowel wall thickening, cardiac anomalies, catheter sepsis [sages.org]

• Malnutrition

  […] intestinal dismotility, intestinal ischemia, intestinal rotation, intestines, IV ABX, IV access, jejunum, Journal of Pediatric Surgery, KUB, Ladds bands, Ladds procedure, lap approach, laparoscopy, leukocytosis, leukopenia, Ligament of Treitz, lysis, malnutrition [sages.org]

  […] by Ladd's bands or when the blood supply is twisted, symptoms may include: Vomiting bile (greenish-yellow digestive fluid) Drawing up the legs Pain in the abdomen (belly) Abdominal distention (swelling) Rapid heart rate Rapid breathing Bloody stools Malnutrition [chp.edu]

  Vomiting – non-bilious and bilious vomiting ( bile vomiting ) Recurrent abdominal pain Lack of appetite Malnutrition Constipation Bloody stools ( hematochezia ) As ischemia develops, abdominal distension and peritonitis will become evident. [healthhype.com]

  These include chronic abdominal pain, malabsorption and malnutrition, and subsequent growth disturbances. Intestinal malrotation occurs in one of every 500 live births in the United States. [cincinnatichildrens.org]

• Weakness

  He feels weak and he looks pale. His urine output is diminished. He was completely normal prior to the onset of vomiting. He has no fever, diarrhea, dysuria or coughing. [hawaii.edu]

  The causes of small bowel obstruction in children are most often volvulus, intussusception, adhesions, or abdominal hernia, a weakness in the abdominal wall that traps a portion of intestine. [yourdictionary.com]

  Gastric volvulus 1ry Congenital weakness of the suspensory ligaments Gastro- splenic Gastro- colic Gastro- hepatic Gastro- phrenic 2ry Diaphragmatic hernia Diaphragmatic eventration Gastric volvulus 11. GS GS GC GH GH Suspensory ligaments 12. [de.slideshare.net]

  Possible causes and risk factors may include: air travel in low cabin pressure colon muscle weakness (atonia) enlargement of the colon Hirschsprung’s disease (where the large intestine becomes inflamed and leads to constipation and obstruction) infections [healthline.com]

  As increases in intraluminal pressure occur, especially in those patients with constipation, there is a tendency for the mucosa to herniate through weak areas where nutrient blood vessels penetrate the colonic wall. [web.archive.org]

• Fatigue

  We ask about general symptoms (anxious mood, depressed mood, fatigue, pain, and stress) regardless of condition. Last updated: January 31, 2019 [patientslikeme.com]

  […] bulging, weak spots on the colon infection trauma Symptoms of Fistulas Some people with a fistula in the lower GI tract have no symptoms; others may experience abdominal pain that begins in one spot and spreads throughout the abdomen dehydration diarrhea fatigue [niddk.nih.gov]

• Vomiting

  Vomiting- A forceful outward throw of the food consumed is referred to as vomiting. Obstipation- Severe or complete constipation of the bowel. Constipation- Difficulty passing out stool every day, with less than three bowel movements in a week. [icliniq.com]

  Patients typically show features of bowel obstruction (abdominal pain, distension, bilious vomiting) or of bowel ischemia and gangrene ( tachycardia, hypotension, hematochezia, peritonitis ) in severe cases. [amboss.com]

  Prolonged vomiting may result in dehydration. Excessive dehydration can cause shock and shock can additionally result in kidney failure. All of the mentioned are life-threatening conditions. [ic.steadyhealth.com]

  Bilious vomiting is the key presenting symptom. A child presenting with green or yellow vomiting should be presumed to have volvulus until proved otherwise. [patient.info]

• Abdominal Pain

  On physical exam, he was alert and oriented, and had abdominal pain but no acute distress. Heart and lung exams were normal. [journals.lww.com]

  Executive Summary Typically, children will complain of severe abdominal pain that is intermittent. [ahcmedia.com]

  The most common symptoms are abdominal pain that is relieved by passage of stool or flatus, abdominal distention and vomiting. Radiologic evaluation often reveals colonic dilation. [aafp.org]

  The patient will complain about severe abdominal pain, flatulence, and accompanying nausea and vomiting. Plain abdominal x ray will point to accumulation of gas and fluids in caecum. CT scan may provide with better insight of the volvulus. [ic.steadyhealth.com]

  CONCLUSION: Volvulus caused by mesenteric masses is a rare but potentially life-threatening cause of abdominal pain, which should be considered in the differential diagnosis of paediatric acute abdominal pain. [ncbi.nlm.nih.gov]

• Nausea

  Symptoms and signs of peritonitis include nausea, vomiting, severe abdominal pain and distension, increased body temperature and chills, excessive thirst and decreased urination. Peritonitis can additionally lead to shock. [ic.steadyhealth.com]

  Symptoms may include abdominal cramping bloody stools constipation nausea signs of shock vomiting People with any of these symptoms should be evaluated immediately by a health care provider. [colorectal.surgery.ucsf.edu]

• Abdominal Tenderness

  The physical examination revealed hypoactive bowel sounds and diffuse abdominal tenderness with rebound; there was no fever, abdominal rigidity, or guarding. [nejm.org]

  Physical examination revealed central abdominal tenderness but no clinical features of peritonism. [ncbi.nlm.nih.gov]

  Abdominal exam is notable for diffuse abdominal tenderness to palpation, without rebound or guarding. Laboratory studies are notable for leukocytosis, though lactic acid is within normal limits. Abdominal x-ray is shown in Figure A. [step2.medbullets.com]

  Physical examination may show mild right sided abdominal tenderness or no abnormalities. [pmj.bmj.com]

• Abdominal Bloating

  Parkinson disease, multiple sclerosis, pseudobulbar palsy) medications from chronic psychiatric conditions (e.g. chronic schizophrenia) Symptoms are that of large bowel obstruction: constipation, abdominal bloating, nausea and/or vomiting. [radiopaedia.org]

  Volvulus Coronal CT of the abdomen, demonstrating a volvulus as indicated by twisting of the bowel stock Specialty General surgery Symptoms Abdominal pain, abdominal bloating, vomiting, constipation, bloody stool [1] [2] Complications Ischemic bowel [ [en.wikipedia.org]

  These patients often have abdominal bloating, constipation, and nausea that may or may not be accompanied by vomiting. SV is thought to be associated with neurological pathologies such as multiple sclerosis and Parkinson’s disease. [news-medical.net]

• Hypotension

  Patients typically show features of bowel obstruction (abdominal pain, distension, bilious vomiting) or of bowel ischemia and gangrene ( tachycardia, hypotension, hematochezia, peritonitis ) in severe cases. [amboss.com]

  Rapid-onset and bilious vomiting, leading to metabolic acidosis, lactataemia, oliguria, hypotension and shock with advancing ischaemia.[8] Careful examination may reveal a palpable abdominal mass in some patients. [patient.info]

  Rapid-onset and bilious vomiting, leading to metabolic acidosis, lactataemia, oliguria, hypotension and shock with advancing ischaemia. [ 8 ] Careful examination may reveal a palpable abdominal mass in some patients. [patient.co.uk]

  Fever, hypotension,and signs ofperitonitis usually indicate bowel gangrene. [cancertherapyadvisor.com]

• Muscle Strain

  strain or trauma muscular infection neurogenic pain: herpes zoster, radiculitis in Lyme disease, abdominal cutaneous nerve entrapment syndrome (ACNES), tabes dorsalis Referred pain from the thorax: pneumonia, pulmonary embolism, ischemic heart disease [en.wikipedia.org]

• Prolapse

  To the best of our knowledge, this is the first report of primary small intestinal volvulus occurring after rectopexy for rectal prolapse. Primary small intestinal volvulus could be a postoperative complication after laparoscopy. [ncbi.nlm.nih.gov]

  The condition is frequently the result of a prolapsed segment of mesentery and occurs most often in the ileum, the cecum, or the sigmoid parts of the bowel. [medical-dictionary.thefreedictionary.com]

  Ileus/Bowel obstruction (Intussusception, Volvulus) - Diverticulitis/Diverticulosis - IBS other functional intestinal disorders (Constipation, Diarrhea, Megacolon/Toxic megacolon, Proctalgia fugax) - Anal fissure/Anal fistula - Anal abscess - Rectal prolapse [bionity.com]

• Oliguria

  We present the case of a 76-year-old man who presented to hospital with severe abdominal pain and oliguria secondary to a volvulus of his ileal conduit. [ncbi.nlm.nih.gov]

  Rapid-onset and bilious vomiting, leading to metabolic acidosis, lactataemia, oliguria, hypotension and shock with advancing ischaemia.[8] Careful examination may reveal a palpable abdominal mass in some patients. [patient.info]

  Rapid-onset and bilious vomiting, leading to metabolic acidosis, lactataemia, oliguria, hypotension and shock with advancing ischaemia. [ 8 ] Careful examination may reveal a palpable abdominal mass in some patients. [patient.co.uk]

  Shock and oliguria are serious signs that indicate either late simple obstruction or strangulation. Obstruction of the large bowel usually causes milder symptoms that develop more gradually than those caused by small-bowel obstruction. [merckmanuals.com]

  Abnormal hemorrhage, hyperbilirubinemia and oliguria are late findings. [aafp.org]

Several tests are employed for diagnosing the condition of volvulus. At preliminary level, preliminary physical examination is carried out after obtaining a careful medical profile of the patient. Thereafter, stool tests are done to determine presence of blood in it. Abdominal X-rays help in confirming the condition of volvulus, especially when they show signs of coffee bean shape of the air filled loop of the colon [8]. If this does not help in arriving at appropriate diagnosis, then barium enema tests would be carried out. Following this, imaging studies such as CT scan of the abdomen would be required which would show signs of intestinal volvulus [9].

• Pneumoperitoneum

  It is believed that a pneumoperitoneum associated to an abnormal movement and handling of the bowel may speed up the clinical picture. The lateral inclinations of the operating table also seem to contribute to it. [scielo.br]

  Carbon dioxide pneumoperitoneum pressure is maintained at 10mmHg. Two other 5mm ports are introduced in the right and left hypochondrium. A 0-degree laparoscope is then used. [websurg.com]

  These include 8 : gastroschisis omphalocele diaphragmatic hernia duodenal or jejunal atresia Plain radiograph Unfortunately, plain radiographs are non-contributory appearing either normal early on or having appearances of a bowel obstruction or even pneumoperitoneum [radiopaedia.org]

  Take care not to perform a barium enema examination in patients with suspected gangrenous bowel, a pneumoperitoneum (as seen on plain abdominal radiographs), or clinical signs of peritonitis. [emedicine.medscape.com]

  Chest and abdominal radiographs revealed the presence of pneumoperitoneum and marked sigmoid distension in the shape of an inverted U. [elsevier.es]

• Hyponatremia

  Blood investigations revealed normal hemogram with hyponatremia. Plain X-ray of abdomen showed multiple air-fluid levels, dilated proximal small bowel loops and absence of gas in colon (Fig. 1). [bmcsurg.biomedcentral.com]

• Colitis

  SETTINGS: The study was conducted at a tertiary referral center for ulcerative colitis in Milwaukee, Wisconsin. PATIENTS: Patients included those with volvulus of the IPAA. [ncbi.nlm.nih.gov]

  IBD (Crohn's, Ulcerative colitis) - noninfective gastroenteritis Other intestinal vascular (Abdominal angina, Mesenteric ischemia, Ischemic colitis, Angiodysplasia) - Ileus/Bowel obstruction (Intussusception, Volvulus) - Diverticulitis/Diverticulosis [bionity.com]

  Those who suffer fom inflammatory bowel disease (IBD), such as ulcerative colitis or Crohn's disease, run a higher risk of experiencing colonic obstructions, including those caused by volvulus. [laparoscopicsurgeons.com]

  Some frail subject may not be suitable for barium meal.[1] Barium enemas are most commonly used to check bowel health; they can help diagnose and evaluate the extent of inflammatory bowel diseases such as ulcerative colitis and Crohn's disease. [en.wikipedia.org]

Under emergency situation, surgical procedures would be required to correct the twisted volvulus. In such procedures, the bowels are corrected and the blood supply re-established. When there are signs of necrosis, the dead tissue is removed and the ends are joined back. In other cases, colostomy or ilesostomy is done, so that the intestinal contents can be removed through the tube [10].

Outcome of patients with volvulus is good if the condition is diagnosed on time and prompt treatment initiated. In cases, when the bowel undergoes necrosis the outcome is poor. This is a potentially life threatening condition, which can further call for secondary complications to set in.

Volvulus that strikes the children or infants usually occurs due to birth defect called congenital intestinal malrotation. In such conditions volvulus occurs during the early years of life. However, there are instances, when the condition can occur even without a malrotation. Other causative factors include adhesions, abnormal intestinal contents can also favor the development of segmental volvulus [2]. Types of volvulus other than segmental volvulus commonly strike the adult population and majorly occur due to constipation and or surplus intestinal tissue [3].

The incidence of malrotation occurs in about 1 in 200 or 1 in 500 live births. Majority of the cases of malroration seldom produce any symptoms and therefore goes unreported. Based on this, the true incidence of the condition is still not known. Symptomatic malrotation is known to occur in 1 in 6000 live births [4]. Colonic volvulus is one of the major causes of large bowel obstruction after diverticulitis and cancer; this is based on the figures available from the US government. Males and females are affected in equal numbers, and the disease strikes the adult population in the eighth decade [5].

Chronic constipation as well as excessively high fibrous diet can exert undue pressure on the sigmoid colon, making it susceptible to torsion. Individuals with a gravid uterus or those with huge pelvic mass are also susceptible to develop volvulus. Repeated attacks of torsion cause the base of sigmoid colon to become shortened. The loop becomes inflamed and forms paddle-like configuration.

Intestinal malrotation is a birth defect, which occurs during fetal development. Three stages make up for the development of bowel during fetal growth period. Factors that interfere with normal rotation of the gut during embryonic development cause volvulus to set in. This in turn is associated with abnormalities concerning the gastrointestinal system, which paves way for development of defects of abdominal wall or condition of congenital diaphragmatic hernia [6].

The onset of volvulus cannot be prevented; more so if it occurs due to congenital defect. The progression of the disease can be prevented by prompt diagnosis and immediate initiation of treatment.

Volvulus primarily occurs due to birth defect known as congenital intestinal malrotation. Malrotation develops when the bowel does not get aligned properly during fetal growth. In such instances the bowel no longer is attached to the abdominal wall, which further causes it to shift from its original position and twist. Volulus can also occur in absence of underlying birth defect. There are several types of volvulus such as sigmoid volvulus, cecal volvulus, gastric volvulus, volvulus neonatorum and volvulus of the small intestine. One of the rare types of volvulus is the volvulus of splenic flexure [1].

• Definition: Volvulus is a condition, characterized by development of twist in the intestine which gradually obstructs the blood flow causing necrosis of the affected part. In such a condition there is axial rotation of a part of the bowel. There are several types of volvulus which are categorized based on underlying etiology.
• Cause: Congenital defect that causes intestinal malrotation is the major cause of volvulus. However, there are other factors that can favor development of volvulus without the presence of malrotation.
• Symptoms: Infants with volvulus would experience signs and symptoms similar to bowel obstruction. These include, nausea accompanied by vomiting, pain in the abdomen, abdominal distention, passing dark colored or blood in stool, constipation and recurrent bouts of vomiting.
• Diagnosis: Preliminary physical examination followed by stool test is done to evaluate the presence of blood in stools. Imaging studies such as CT scan of the abdomen would provide more useful insights about the condition. In addition, barium enema test is also indicated. In many instances, X-ray of the abdomen would be enough to arrive at a definite diagnosis. When the findings are inconclusive, then other tests are required.
• Treatment: Presence of severe signs and symptoms would indicate immediate hospitalization in order to prevent secondary complications to set in. Such a kind of situation would indicate immediate surgical procedures to correct the twisted intestine. The part of the intestine that has undergone necrosis would also be removed and the healthy ends joined back. Procedures such as ileostomy or colostomy may be performed depending on the condition.

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6. Stewart DR, Colodny AL, Daggett WC. Malrotation of the bowel in infants and children: a 15 year review. Surgery 1976; 79:716.
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10. El-Gohary Y, Alagtal M, Gillick J. Long-term complications following operative intervention for intestinal malrotation: a 10-year review. Pediatr Surg Int. Feb 2010;26(2):203-6.