Bowel Malrotation in Newborn Babies

Of the cases we have handled for infants injured as a result of medical negligence relating to intestinal or bowel issues, two suffered life threatening injuries. In both cases the physicians failed to promptly diagnose and treat a malrotated bowel with a resulting midgut volvulus. The signs and symptoms for each of these infants were as follows.

Baby 1:

The first infant ("Baby 1") was taken to the hospital by his parents when he was 3 days old. He had been "spitty" with perceived abdominal pain. Upon examination at approximately 12:30 p.m. by his physician, Baby 1's abdomen was firm but his bowels were non-distended. The physician indicated that she would have an abdominal x-ray performed if Baby 1's abdominal girth increased or if he started vomiting. That afternoon, Baby 1 began to experience vomiting with feeds. By 7:11 p.m. the nurses notes stated:

"Child has vomited 6-7 times since 3 p.m. feeding. Emesis has been formula colored to light green in color. Dr. notified of repeated vomiting. Child more pale than earlier.

By 8:10 p.m. Baby 1's abdomen was distended and he had vomited 10 times within a 1 hour period. At approximately 8:30, Baby 1 was examined by two residents at the hospital. After examining Baby 1 and acknowledging the distended abdomen and green colored vomit, both physicians decided to see how the baby did through the night.

As the night went on, Baby 1 nurses began to chart "vomiting bile" every hour. Even so, no physician was contacted throughout the night and early morning hours. At approximately 5:00 a.m. a physician doing rounds checked on Baby 1 and, after seeing the chart, order an upper GI stat to rule of malrotation and volvulus. Ultimately, the UGI confirmed the malrotated bowel with a midgut volvulus and Baby 1 was emergently taken to the operating room.

Unfortunately, as a result in the delay in diagnosis, Baby 1 lost all but 19 cm of his small bowel. Baby 1 went on to require TPN and G-tube feedings. He also developed liver damage as a result of the long term TPN and his liver failed. Fortunately, Baby 1 received a combined liver/small bowel transplant and went on to survive. However, he will be on life long immunosuppressants and has many risk factors he will live with the remainder of his life.

Baby 2:

The second infant ("Baby 2") was taken to the hospital at 6:55 p.m. by his parents when he was only 4 days old. In the emergency room the parents informed nurses that Baby 2 had been vomiting, had not had a bowel movement and was lethargic. They also informed the ER nurse that at 3:30 p.m. Baby 2 had taken 1 oz. of breast milk "then vomited bile green fluid." An x-ray of the abdomen was ordered at 8:00 p.m. and reflected the following:

Radiology Report: The patient has some air noted in the stomach and in bowel loops extending to the level of the rectum. The bowel loops are slightly more prominent on the left side. *** Something such as a malrotation and mid gut volvulus could have this appearance, however, the bowel does not appear to be greatly distended and the bowel loop on the right inferiorly appears to be more likely to represent descending colon with some air within it.

Baby 2 was admitted to the hospital. From 8:00 p.m. through 10:30 p.m. the nurses notes continued to reflected that Baby 2 was having "yellow colored emesis." At 10:52 p.m. Baby 2's physician noted the following:

We did a flat plate of the abdomen that showed a mildly distended stomach with a distended loop of bowel in the left side.
Assessment: 1. Possible viral illness. 2. Possible sepsis. 3. Possible early bowel obstruction, malrotation possible.

The physician went on to tell the parent that Baby 2 has a "little twist" in his bowel and that he would probably need to undergo surgery the following morning. Throughout the night Baby 2's nurses noted that the "yellow colored emesis" had turned to "green" and that "bilious stomach secretions continue to return from NG tube."

Ultimately, Baby 2 was transported to a tertiary care center where he underwent emergency surgery for a bowel obstruction. Unfortunately, the damage had already been done and Baby 2 lost all but 17 inches of his small bowel. Baby 2 went on to require total parenteral nutrition (TPN) and multiple surgical procedures targeted at lengthening his small bowel as he grew.

Signs and Symptoms of Malrotation of the Bowel with Midgut Volvulus:

As both cases proceeded through litigation, we asserted that the treating physicians failed to recognize the clear signs and symptoms of a malrotated bowel. As support we identified the following medical information:

From Current Pediatric Therapy, 16th Edition, "Neonatal Intestinal Obstruction, p. 336, Gellis & Kagan's (1996), we pointed out:

"The neonate who presents with bilious vomiting is presumed to have a surgical abdomen. Malrotation with midgut volvulus must be considered the primary diagnosis until proven otherwise."

From Neonatology : Pathophysiology and Management of the Newborn, by Avery, Fletcher and MacDonald, 1994 (Chapter 37 - Gastrointestinal Disease), we pointed out:

"Rotational anomalies of the small intestine present with emesis, bilious vomiting being the hallmark of malrotation and midgut volvulus in the neonate. *** The physical examination may be normal in as many as 50% of patients, but others present with distention, tenderness, and even signs and symptoms of the acute onset of shock and peritonitis."

From Pediatric Surgery Update, Malrotation: The Deadly Vomit, Volume 1, July 1993), we pointed out:

"Post-prandial bilious vomiting in the early stage of life (usually the first three months) should always prompt the diagnosis of malrotation associated to midgut volvulus."

From Neonatal Gastroenterology, Vol. 23, Number 2, (June 1996), "Surgical Conditions of the Neonatal Intestinal Tract", p.365, we pointed out:

"Vomiting is the most common and important sign in malrotation with midgut volvulus. In a review of 22 patients treated at Children's Hospital in Cincinnati, all 22 had vomiting as their initial symptom, and the emesis was bilious in 17 of 22. It must be remembered that it is abnormal for an infant to vomit bile, and this sign demands consideration of midgut volvulus. In an infant who is a few days to a few weeks old, who is doing fine, and who suddenly vomits bile or bile-stained feeds, malrotation with midgut volvulus should be the leading diagnosis."

From Archives of Pediatric Adolescent Medicine, Vol. 148, (January 1994), "Midgut Volvulus - An Ever-Present Threat", we pointed out:

"Conclusion: Neonates with a short history of bilious vomiting are most likely to have MGV complicating malrotation. ... Since there is no way to predict which patients will develop catastrophic bowel necrosis, early diagnosis and operation are necessary to prevent mortality and short-gut syndrome."

From the facts in both cases it was clear that malrotation with a midgut volvulus should have been diagnosed much early than it was.

Malrotation with Midgut Volvulus: A True Surgical Emergency:

As each case developed it was clear that the physicians did not recognize the dangers associated with a possible diagnosis of a malrotated bowel. On behalf of both Baby 1 and Baby 2 we asserted that the treating physicians failed to recognize that a malrotated bowel with a midgut volvulus was a surgical emergency for each baby. As support we identified the following medical information:

From Pediatric Surgery, Fourth Edition, Vol. 2, "Malrotation of the Intestines", p.886 (1986) we pointed out:

"Midgut volvulus is one of the most serious emergencies seen in the neonate or infant. *** Intestinal obstruction in the newborn requires urgent relief. The possibility of volvulus accentuates that urgency, since a few hours may be the difference between a totally reversible condition on the one hand and loss of most of the intestines on the other."

From Archives of Pediatric Adolescent Medicine, Vol. 148, January 1994, we pointed out:

"Midgut volvulus is usually thought to be an acute catastrophic complication of malrotation in which the need for immediate surgery is obvious.

From Neonatology: Pathophysiology and Management of the Newborn, by Avery, Fletcher and MacDonald, 1994 (Chapter 37 - Gastrointestinal Disease), p.614, we pointed out:

"Symptomatic rotational abnormalities require urgent surgical exploration since a volvulus may result in loss of the entire midgut within hours of presentation due to vascular occlusion".

From Neonatal Gastroentrology, Vol. 23, Number 2, (June 1996), "Surgical Conditions of the Neonatal Intestinal Tract", p. 366, we pointed out:

"The time from initial symptoms to intestinal infarction can be as little as a few hours making this a true surgical emergency. *** It is safer to proceed with a negative laparotomy than to miss midgut volvulus."

From Current Pediatric Therapy, 16th Edition, "Neonatal Intestinal Obstruction, p. 336, Gellis & Kagan's (1996), we pointed out:

"Once a diagnosis of malrotation is made, aggressive intervention is mandated to avoid an undesirable outcome. If volvulus is present, intestinal necrosis can result within 6 hours.

From Pediatric Surgery Update, "Malrotation, the Deadly Vomit, Volume 1, July 1993), we pointed out:

"Ischemic bowel will die in a six to eight hour period if not treated promptly by detorsion and Ladd's procedure."

During the litigation it became clear that in both cases the delay in the diagnosis of the malrotated bowel and midgut volvulus led to the loss of almost the entire small bowel for each of these babies.

Resolution of Cases:

Based on the facts, the above literature and the expert opinions in the case from experts we retained for our clients', both cases settled prior to trial for a confidential amount.