A RARE CASE OF MIDGUT

VOLVULUS
A CASE REPORT
Dr Muhammad Javaid Khan
PG Trainee
Department of Pediatric Surgery,
Services Hospital, Lahore
PARTICULARS OF THE PATIENT
Name: Master A
Age: 13 years
Sex: Male
Weight: 20 kg
Date of admission: 29 July 2015
Mode of admission: Referred from Paeds Medicine
 PRESENTING COMPLAINTS
• Abdominal pain 5 days
• Abdominal distension 1 day
• Vomiting 1 day
HISTORY OF PRESENTING ILLNESS

• My Patient was in usual state of health 5 days ago when he

developed pain in periumbilical region
• Sudden in onset, colicky in nature, moderate in severity
• No relation to food intake
• Partially relieved by analgesics
• Severe in intensity and continuous for the last 12 hours
• Vomiting
Bilious
2-3 episodes
• Patient was treated initially by Paediatric medicine on the line
of Diabetic ketoacidosis
• ASOC with High BSR and abdominal pain
• Later on ABG’S and urine for ketones turned out to be normal
• Call was sent to paediatric surgery
GENERAL PHYSICAL EXAMINATION
• A pale looking child in ASOC rolling in the bed
• Thready peripheral pulse
• Vitals-
Pulse: 150 beats per minute Temperature: 98.6 °F
RR: 30breaths per minute BP: 80/50 mm Hg
 SYSTEMIC EXAMINATION
Abdomen:
• Moderately Distended
• Visible gut loops
• Tense and tender especially in epigastric and umbilical region
• No mass palpable
• Bowel sounds: Absent
• Hernial orifices were intact
 RECTAL EXAMINATION
• Normal
• No mass palpable
• Finger not stained with blood
 SYSTEMIC EXAMINATION
• Rest of the systems: unremarkable
 INVESTIGATIONS
Hemoglobin: 10.1 gm/dl
Total leucocyte count: 21 x 10³ / µL
Platelet count: 427 x 10³/ µL
S. Sodium: 137 mmol/L
S. Potassium 4.5 mmol/L
BSR: 289 mg/dl
B.Urea:
S.Creatinine: Within normal range
Liver function test:
Coagulation profile:
 USG ABDOMEN
• Done in ER
• Minimal ascites with multiple dilated bowel loops
• No evidence of mass
 DIFFERENTIAL DIAGNOSIS
Intestinal obstruction
 Volvulus
 Intussusception
 PLAN

Exploratory laparotomy following optimization of the patient

 PREOPERATIVE PREPARATION
• NPO
• Nasogastric decompression
• Catheterization
• IV fluid
• Antibiotics
• Blood arranged
 EXPLORATORY LAPAROTOMY
• Right supraumbilical transverse incision
 OPERATIVE FINDINGS
• About 300 ml of brownish black fluid in the peritoneal cavity

• Twisting of small gut(volvulus) leading to gangrene

• About 3 inches of proximal jejunum & 2 inches of distal ileum

viable

• DJ junction was to the right of midline and base of mesentery

was short
• Detorsion of gut and warm packs, 100% oxygen

• Resection of devascularized gut and anastomosis of viable

ends done

• Ileocecal area was saved

 OUR WORRY !
• Too much length of intestine resected
• Short gut syndrome
 POSTOPERATIVE
• Postoperative course was uneventful
• Started TPN and continued for 02 weeks
• Oral fluids allowed at 6th post operative day.
• Developed loose stools, dietary modification and loperamide
• Discharged on 16th postoperative day
• Weight at discharge was 18.5 kg
 FOLLOW UP
• Regular
• Counselling regarding modified diet
• Initially every 15 days for 02 months
• Now patient is being followed on monthly basis
• Monitoring growth
• According to the parents he is passing stool with:
• Normal consistency
• Sometimes loose stools
• Two to three times a day
• Weight is same as it was at the time of discharge
 LITERATURE REVIEW

• Extremely rare in adolescent age group

• Only a few case reports
 TAKE HOME MESSAGE
• High index of suspicion
• Immediate surgical exploration