Snapshot A 2-day-old neonate presents with bilious vomiting and irritability. On physical examination, she has abdominal distention and high-pitched bowel sounds. Barium enema radiograph reveals a dilated sigmoid colon with a column of barium resembling a "coffee bean". Introduction Malrotation of gut from errors during development increases risk of volvulus Volvulus (typically, midgut) abnormal rotation of bowel strangulation of SMA compromised blood flow to bowel Epidemiology most common in newborns males > females Associated conditions situs inversus cardiovascular defects heterotaxy gastroschisis/omphalocele Presentation Symptoms neonates bilious vomiting within first week of life colicky pain older patients bilious or nonbilious vomiting crampy abdominal pain change in bowel pattern nausea Physical exam abdominal distention abdominal tenderness Evaluation abdominal radiography may have air fluid levels upper GI imaging with barium enema “bird beak” appearance at site of rotation failure of duodenum to cross midline = malrotation Differential Diagnosis Intussusception Intestinal atresia Gastroenteritis Appendicitis Meckel diverticulum Treatment Malrotation without volvulus elective Ladd procedure Malrotation with volvulus (symptomatic or acute abdomen) emergent endoscopic decompression surgical decompression Prognosis, Prevention, and Complications Prognosis good with treatment Complications bowel necrosis perforation sepsis