P3.M255: Exploring Pediatric Colonic Volvulus: A Case Study and Diagnostic Considerations

Introduction: Colonic volvulus, a rare occurrence, comprises approximately 3% to 5% of all large bowel obstructions in adults, with even fewer cases in children. Among these, sigmoid colon volvulus is the most prevalent, followed by cecal and transverse colon volvulus. Clinical presentation often poses a challenge due to nonspecific symptoms that can mimic constipation or gastroenteritis. Diagnosis heavily relies on radiographic evidence, with specific findings such as the coffee-bean sign, absence of rectal gas, and focal colonic loop dilation prominent on abdominal radiographs. Confirmation typically involves a barium enema, also serving as a therapeutic measure. Additionally, the bird’s beak appearance on contrast enema studies is indicative of the point of obstruction from the colonic twist. However, while computed tomography (CT) is a commonly utilized in adult volvulus, its efficacy in pediatric cases remains uncertain. In this study, we present a case of colonic volvulus in an infant, highlighting characteristic findings observed on abdomen X-ray and colon enema imaging.

Case Description: A 9-month-old male presented to the pediatric emergency department with abdominal pain and distention, fussiness and refusing oral intake for one day. History of full term and NICU admission for respiratory failure for two weeks, immediately after birth. Initial assessment revealed non-compensated high anion gap metabolic acidosis, leukocytosis with bandemia and elevated Procalcitonin. Abdomen X-ray demonstrated massive distention of the ascending, transverse, and descending segments of the colon with abrupt cut off in the mid pelvis. (Fig 01). X-ray barium enema shows opacification of a small caliber descending and distal transverse colon. Tapered obstruction at the level of the transverse colon with a beaked appearance with proximal massive dilatation. (Fig 02) Findings indicative of colonic volvulus with complete obstruction. Diagnosis was confirmed by laparotomy where a malrotation with volvulized and no viable segment in the distal ileum, ascending and transverse colon was found and resected.

Discussion: Historically only 40 cases of a proximal large bowel volvulus in children have been reported in the literature with associated mortality of 14%. Plain abdominal radiography serves as a pivotal initial diagnostic tool, followed by contrast enema studies in stable patients without evidence of perforation or septic shock. Despite the increasing availability of CT scans, their use in pediatric cases remains limited, due to the necessity for additional anesthesia.

Conclusion: Our case underscores the importance of considering colonic volvulus as potential diagnosis in pediatric patients presenting with abdominal symptoms. The diagnostic approach, relying on abdominal radiographs and contrast enema studies, remains crucial in promptly identifying this condition. While computed tomography scans may offer additional diagnostic insights, their utility in pediatric cases warrants further investigation. Early recognition and intervention are paramount to prevent complications and improve outcomes in pediatric patients with colonic volvulus.