Management of Malrotation

Malrotation classically presents as a full-term infant with bilious emesis. Any patient who presents with bilious emesis should be assumed to have malrotation with a midgut volvulus until proven otherwise. Initial workup should include a physical examination to rule out peritonitis or hemodynamic instability, followed by an abdominal X-ray to evaluate for proximal or distal bowel obstruction or a surgical emergency, such as pneumatosis or free air. Any patient with a worrisome physical exam or abdominal X-ray findings should be taken to the operating room (OR) emergently to rule out malrotation with midgut volvulus. The current gold standard in diagnosing malrotation is an upper gastrointestinal contrast study, and the key feature to look for is the location of the duodenal-jejunal junction (DJJ). In patients with an abnormal DJJ position, the treatment is a Ladd’s procedure. This chapter presents an algorithm that discusses the work-up and management of a patient with malrotation.