Volvulus is the most serious etiology of intestinal obstruction Neonates with bilious emesis should be emergently evaluated for malrotation and volvulus even if well-appearing Sudden onset of abdominal pain and bilious emesis in a child should prompt rapid evaluation for midgut volvulus Current Evidence Malrotation of the bowel is a congenital condition associated with abnormal fixation of the mesentery of the bowel ( Fig 116.9 ) Therefore, the bowel has a tendency to volvulize and obstruct at points of abnormal fixation Although malrotation with volvulus usually occurs either in utero or during early neonatal life, malrotation can be unrecognized until childhood (25% of cases present after year of age) This is an extraordinarily dangerous situation because a complete volvulus of the bowel for more than an hour or two can obstruct blood supply to the bowel completely, leading to complete necrosis of the involved segment When a volvulus involves the midgut, the entire small bowel and ascending colon may be lost To prevent such a catastrophe, physicians should have a high index of suspicion for malrotation in any child with signs of obstruction and be prepared to get a child with a presumed volvulus to the operating room immediately Clinical Considerations Initial Assessment Any child with bilious vomiting and abdominal pain may have malrotation with volvulus The pain is usually intense and constant, although infants with early volvulus may initially appear well Blood may appear in the stool within a few hours and suggests the development of ischemia and possible necrosis of the bowel Clinically, malrotation can present in several different ways: first, and most dangerous, is the sudden onset of abdominal pain with bilious vomiting with no prior history of GI problems; second is a similar abrupt onset of obstruction in a child who previously seemed to have “feeding problems” with transient episodes of bilious vomiting; and third is a child with failure to thrive because of alleged intolerance of feedings