Information
Malrotation is spectrum of anatomical variants that involves an incomplete rotation of the bowel. This can result in a narrowed mesenteric base and lack of intestinal fixation. This predisposes risk of twisting of the bowel and midgut volvulus/obstruction resulting in disruption to the blood supply. If untreated, this can cause widespread ischaemia and bowel necrosis.
Clinical Features and Epidemiology:
- Age: mainly presents within first days to month of life. May less commonly be seen in older infants.
- Bilious vomiting: vomiting that is green in colour. Note that gastric juice is often yellow in colour however bilious vomits are distinctly green.
- Associated symptoms: most babies with malrotation and volvulus are completely asymptomatic in the early stages, with the only symptom being bright green vomit. It can also be associated with acute onset abdominal pain (may be inconsolable), and later signs of dehydration.
- Examination: note examination of the abdomen is normal. Features such as distention and peritonism are only seen late if left untreated.
Differentials:
- Sepsis: bilious vomiting associated with systemic symptoms such as pyrexia, distress, blood in stool, and deranged observation markers.
- Gastroenteritis: bilious vomiting at the end of multiple non-bilious vomits.
- Bowel obstruction: bilious vomits, abdominal distension, absence of flatulence/stool. May be associated with abdominal pain.
- Small bowel atresia: symptoms will be present from day of birth. Mainly detected via antenatal scans.
- Meconium ileus: retained meconium causing obstruction. Associated with cystic fibrosis. May or may not have passed initial meconium. Meconium often thicker and stickier than usual.
Who to refer:
- Any neonate or infant with bilious vomiting. Refer as an EMERGENCY
How to refer:
NHS Lothian
- Bleep the on call paediatric surgery FY or surgical registrar via RHCYP switchboard and send the neonate/infant to RHCYP A&E. Clinical details can be discussed over the phone.
- Keep the patient fasted until they are assessed in hospital
NHS Fife, Tayside, and Borders
- Refer to your local ED urgently who will then re-assess and refer on to RHCYP.
Advice to parents:
- What to expect when arriving at the hospital – re-examination, scan of the abdomen if malrotation is suspected +/- NG tube to administer contrast dye.
