Malrotation and volvulus — formative SAQs

SAQ 1 (10)

A three-day-old term baby, who fed and stooled normally in hospital and was discharged home, is brought to the emergency department after vomiting a mouthful of bright green fluid. On examination the baby is alert and afebrile, with a soft and only slightly full abdomen, normal femoral pulses and no hernial or perineal abnormality. The plain abdominal radiograph is reported as unremarkable. The admitting team documents the vomit as bilious. [1] [2]

a) State the governing clinical rule that should drive this baby's management, and explain why a well-looking baby with a normal plain film does not lower the suspicion of midgut volvulus. (3 marks) [1] [2]

b) Outline the immediate resuscitation and stabilisation, including the fluid bolus you would give for shock, nasogastric management, and the indication for antibiotics. (3 marks) [2]

c) Name the reference imaging investigation, state the diagnostic sign you are looking for, and describe the additional sign that would indicate an actual volvulus. Explain why the plain film cannot be reassuring. (2 marks) [2]

d) The baby becomes increasingly lethargic with abdominal tenderness and passes blood per rectum. Describe the definitive operation and its steps, and state in which direction the volvulus is detorsed and why. (2 marks) [6]

SAQ 2 (10)

A fourteen-year-old girl presents to the general paediatric clinic with a two-year history of recurrent vomiting that she and her mother describe as occasionally green, intermittent central abdominal pain that wakes her at night, and a fall across the weight centiles. Previous assessments have labelled her symptoms as cyclic vomiting and functional abdominal pain. She is between attacks and her examination is normal. [5] [2]

a) What is the most likely unifying diagnosis that explains the bile, the pain and the faltering growth, and why has it been repeatedly missed? (3 marks) [5]

b) State the investigation that will confirm or exclude the diagnosis, what you expect it to show, and an additional bedside modality that may support it. (3 marks) [2]

c) The contrast study confirms malrotation. Outline the surgical management and the reasoning behind one step that may seem incidental to the family, namely removal of the appendix. (2 marks) [6] [4]

d) Separately, a colleague asks whether an incidental malrotation found on a contrast swallow done for reflux in an asymptomatic two-year-old should always be operated on. State what the evidence advises and the principle that governs the decision. (2 marks) [4]