Management of Midgut Volvulus

Diagnostic Approach

The American College of Radiology recommends obtaining plain abdominal radiographs first, though normal films do not exclude malrotation or volvulus, and looking for signs of proximal bowel obstruction, abnormal gas patterns, or pneumatosis intestinalis suggesting ischemia 1, 2
Upper GI series is the reference standard for diagnosing malrotation and volvulus, showing abnormal position of the duodenojejunal junction (ligament of Treitz), with 96% sensitivity but can have false-positives (10-15%) and false-negatives due to redundant duodenum or bowel distension 1
Ultrasound with color Doppler can identify the "whirlpool sign" (clockwise wrapping of the superior mesenteric vein and mesentery around the superior mesenteric artery), which is highly specific for midgut volvulus 2

The American College of Radiology suggests proceeding urgently to laparotomy or laparoscopy for Ladd procedure, which involves detorsion of the volvulus, division of Ladd bands, widening of the mesenteric base, appendectomy, and placement of bowel in non-rotated position 1, 2

Do not delay surgery for contrast enema, as this has no role in diagnosing or managing midgut volvulus 1, 2

Upper gastrointestinal (UGI) series is the reference‑standard test for diagnosing intestinal malrotation; it identifies an abnormal duodeno‑jejunal junction with a sensitivity of ≈ 96 %, while false‑positive results occur in about 10–15 % of examinations due to redundant duodenum or bowel distension. 3
Color‑Doppler ultrasound showing the “whirlpool sign” (clockwise wrapping of the superior mesenteric vein around the superior mesenteric artery) provides a highly specific confirmation of midgut volvulus in suspected malrotation. 3
Contrast enema has no diagnostic or therapeutic role in acute midgut volvulus and yields a false‑negative rate of roughly 20 % for detecting malrotation; therefore, surgery should not be delayed while awaiting this study. 3

Indocyanine green (ICG) fluorescence angiography can be used intra‑operatively to assess bowel perfusion, helping surgeons delineate the extent of ischemic intestine and decide on the need for resection. 4