• Clinical science

Volvulus and intestinal malrotation


Volvulus is defined as the twisting of a loop of bowel on its mesentery and is one of the most common causes of intestinal obstruction. The sigmoid colon, and less frequently, the cecum, are the common sites of volvulus in adults. Volvulus in a neonate or infant almost always presents as a midgut volvulus secondary to intestinal malrotation. 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. The whirl sign and a grossly dilated loop of bowel on an abdominal CT scan establish the diagnosis of volvulus in adults. Upper GI series is the investigation of choice in infants with suspected midgut volvulus, which is seen as a cork-screw duodenum. Sigmoid volvulus without peritonitis is initially managed with endoscopic detorsion, followed by a semi-elective surgery (sigmoid colectomy). Sigmoid volvulus with peritonitis, and all cases of cecal volvulus, require emergency surgery. Endoscopic detorsion should not be attempted in a patient with cecal volvulus because of the high risk of perforation. The Ladd procedure (laparotomy and detorsion of the volvulus) is indicated in all patients with intestinal malrotation since it is impossible to predict if volvulus of the midgut will occur in an asymptomatic patient or not.



Epidemiological data refers to the US, unless otherwise specified.



Risk factors for the development of a volvulus


Sigmoid volvulus

Clinical features

Differential diagnoses


  1. Initial resuscitation: IV fluids; acid-base and electrolyte imbalance correction; NPO; placement of a nasogastric tube
  2. Evaluation
    • No signs of peritonitis: rigid/flexible sigmoidoscopic detorsion of the volvulus → inspection of the mucosa for signs of ischemia
      • No signs of mucosal ischemia → placement of a soft rectal tube (for bowel decompression) → semi-elective surgery within 72 hours of detorsion
      • Signs of mucosal ischemia → emergency surgery (see below)
    • Signs of peritonitis/unsuccessful endoscopic detorsion → broad-spectrum IV antibiotics and emergency surgery
  3. Surgery


Cecal volvulus


Clinical features

  • Acute presentation: features of small bowel obstruction
  • Insidious onset: recurrent episodes of right lower abdominal pain

Differential diagnoses


  1. Initial resuscitation (See “Treatment” of sigmoid volvulus above.)
  2. Surgery
    • Hemodynamically stable patients: ileocecal resection or right colectomy with ileocolic anastomosis
    • Hemodynamically unstable patients
      • Cecostomy
      • Detorsion with cecopexy


Intestinal malrotation and midgut volvulus


  • Intestinal malrotation: arrest in the normal rotation of the gut in utero, resulting in an abnormal orientation of the bowel and mesentery within the abdominal cavity
  • Normal intestinal rotation: the midgut starts to elongate in utero (4th week) herniation of the midgut out of the umbilicus (6th week) → 90° counter-clockwise rotation of the midgutre-entry of the midgut into the abdominal cavity(10th week) → 180° rotation inside the abdominal cavity (a total of 270°) → fixation of the duodenojejunal flexure and cecum to the posterior abdominal wall
Common types of intestinal malrotation
Nonrotation Incomplete rotation
  • The mesenteric attachment has a wider base than in incomplete rotation

Clinical presentation

Differential diagnoses


  • Midgut volvulus with/without peritonitis
    • Initial resuscitation: nil per oral; nasogastric tube insertion; IV fluids; correction of electrolyte imbalance; broad-spectrum IV antibiotics
    • Emergency surgery (Ladd procedure)
  • Incidentally detected/asymptomatic intestinal malrotation: elective surgery (Ladd procedure)




Intestinal malrotation and midgut volvulus

Imaging in intestinal malrotation and midgut volvulus

Intestinal malrotation

Midgut volvulus

Upper GI series (gold standard in hemodynamically stable patients)

  • Displaced duodenojejunal junction
Barium enema (lower GI series)
Abdominal ultrasound
  • Abnormal position of the superior mesenteric vessels and bowel
  • Whirlpool sign (on color doppler)

CECT scan (oral and IV contrast)