Malrotation and volvulus

Malrotation and volvulus
Introduction
What is malrotation?
What is volvulus?
What are the symptoms of malrotation and volvulus?
What causes malrotation and volvulus and how common are they?
How is malrotation and volvulus diagnosed?
How are they treated and are there any alternatives?
What happens before the operation?
What does the operation involve?
Are there any risks?
What happens afterwards?
When you go home
What is the outlook for children with malrotation and volvulus?
Support group
Introduction
This leaflet explains about malrotation and volvulus, how they can be treated, and what to expect when your child comes to Great Ormond Street Hospital.What is malrotation?
Malrotation is an abnormality of the bowel, which happens while the baby is developing in the womb.
Early in pregnancy, the bowel is a long straight tube leading from the stomach to the rectum. The bowel then moves into the umbilical cord temporarily while it develops into the large and small bowel.
Around the tenth week of pregnancy, the bowel moves back into the abdomen and coils up to fit into the limited space there. If the bowel does not coil up in the correct position, this is called malrotation.
Malrotation can be associated with other problems, but the doctors will examine your child closely to check if this is the case.What is volvulus?
This is a complication of malrotation and occurs when the bowel twists so the blood supply to that part of the bowel is cut off.What are the symptoms of malrotation and volvulus?
Malrotation may not have any symptoms. Many people are never diagnosed with malrotation because it causes no problems. However, bands of tissue (adhesions), which block the first part of the small bowel (duodenum), can develop. This means food cannot easily pass through the duodenum to the rest of the bowel for digestion.
The symptoms of volvulus are usually the first sign of malrotation. They include sudden bouts of crying and pulling the legs into the body, which then stop suddenly. This is caused by cramps, as the bowel cannot push food and liquid past the twisted section of bowel. As little/no food or liquid can pass the twisted portion, your child may also pass little or no faeces (poo). Vomiting is another symptom of volvulus, as your child is unable to digest food as usual.
If the condition is not treated, your child will become dehydrated which can be life-threatening. the symptoms of dehydrationmay appear in phases, and include lethargy, wet nappies less frequently than normal and the soft spot (fontanel) on the top of the head may be sunken.What causes malrotation and volvulus and how common are they?
We do not know exactly what causes malrotation and volvulus, but it is not due to anything that happened during pregnancy. Malrotation affects about one in every 2,500 to 3,000 babies, and boys and girls in equal numbers.How is malrotation and volvulus diagnosed?
Malrotation and volvulus are usually diagnosed using x-rays. A barium x-ray may also be useful as it shows the feeds being unable to pass the twisted part of the bowel. The doctor may also suggest an ultrasound scan, like the ones used in pregnancy, to get a picture of the abdomen.
The majority of children with malrotation showing symptoms are diagnosed by the age of one. How are they treated and are there any alternatives?
Adhesions and volvulus are usually treated in an operation under general anaesthetic. They both require emergency treatment as the bowel can die off from lack of blood-supply, which would stop it functioning properly and can also lead to problems with infection. The effects of the adhesions and volvulus, like dehydration due to the lack of fluids being absorbed, can become serious quite quickly in children, and so there are no alternatives to the operation. What happens before the operation?
You will receive information about how to prepare your child for the operation in your admission letter and our welcome booklet.
Your child’s surgeon will explain the operation in detail, discuss any worries you may have and ask your permission for the operation by asking you to sign a consent form. An anaesthetist will also visit you to explain about your child’s anaesthetic in more detail and discuss options for pain relief after the operation. If your child has any medical problems, like allergies, please tell the doctors.
If your child is dehydrated, he or she will need a ‘drip’ of fluids for a while before the operation. Your child will also need a nasogastric tube, which is passed up the nose, down the food-pipe and into the stomach. This will drain off the stomach and bowel contents and ‘vent’ any air that has built up, which will make your child more comfortable. What does the operation involve?
The operation is called a Ladd procedure. The surgeon will straighten out the twisted bowel and separate any adhesions. If the bowel looks healthy, the surgeon will coil it back into the abdomen. Usually the surgeon will also remove the appendix during this operation, as it is often on the wrong side of the body in malrotation, which could cause problems in diagnosing appendicitis later in life.
The surgeon will remove any parts of the bowel where tissue has died. The amount can vary, but the surgeon will leave as much of the bowel as possible. If the surgeon has to remove a large part of the intestine, he or she may need to create an artificial way of disposing of waste matter, called a ‘stoma’. If your child is likely to need a stoma, the stoma care nurse specialist will visit you to explain further. Are there any risks?
All the doctors who perform this operation have had lots of experience, which will minimise the chance of problems occurring.
All surgery carries a small risk of bleeding during or after the operation. Every anaesthetic carries a risk of complications, but this is very small. Your child’s anaesthetist is an experienced doctor who is trained to deal with any complications. What happens afterwards?
Your child will come back to the ward to recover. He or she will have been given pain relieving medications during the operation, but these will begin to wear off. For the first few days, pain relief will usually be given through a ‘drip’ and then, when your child is more comfortable, in the form of medicines to be swallowed.
For the first few hours, your child will need to be fed through a tube into his or her veins (total parenteral nutrition or TPN) so the stomach and bowel can start to heal. After a while, you can start to feed your child again, starting with small amounts, and increasing the amount as he or she tolerates it.
Your child will be able to go home once he or she is feeding well and starting to gain weight. We will contact your health visitor and GP to tell them about the operation.When you go home
Your child’s abdomen may feel sore for a while after the operation, but wearing loose clothes can help. Your child will need to have regular pain relief for at least three days, and we will give you the medications to take home with you. As well as the medications, distracting your child by playing games, watching TV or reading together can also help to keep your child’s mind off the pain.
The stitches used during the operation will dissolve on their own so there is no need to have them removed. If possible, keep the operation site clean and dry for two to three days to let the operation site heal properly. If your child needs to have a bath, do not soak the area until the operation site has settled down.
You may need to come back to hospital for an outpatient appointment after the operation. We will send you the appointment date in the post.What is the outlook for children with malrotation and volvulus?
The outlook depends on how quickly the malrotation and volvulus are diagnosed as this in turn can influence the amount of damage to the bowel. If your child had a large amount of bowel removed, he or she may need to stay on TPN for a longer period, sometimes for a year or longer, until the bowel can absorb enough nutrients for normal growth and development. Adhesions can form after any abdominal surgery, and can cause discomfort.Support group
Gut Motility Disorders Support NetworkWestcott FarmOakfordTiverton EX16 9EZTel: 01398 351173Email: help@gmdnet.org.uk
You should call your family doctor or the ward if:• your child is in a lot of pain and pain relief does not seem to help• your child is not keeping any fluids down or has signs of dehydration• your child has a high temperature of 37.5°C or higher, a paracetamol does not bring it down• the operation site is red or inflamed, and feels hotter than the surrounding skin• there is any oozing from the operation site.If you have any questions, please call Rabbit Ward on 020 7829 8818 or Hedgehog Ward on 020 7829 8819.

Ref: 2004F070Compiled by the General Surgery Department and the Pain Servicein collaboration with the Child and Family Information Group.


This information does not constitute health or medical advice and will not necessarily reflect treatment at other hospitals. If you have any questions, please ask your doctor. No liability can be taken as a result of using this information.