Andrew Grock, MD; Wendy Chan, MD; Ian S. deSouza, MD


Western J Emerg Med. 2016;17(5):630-633. 

In This Article

Abstract and Introduction


An otherwise healthy 36-year-old man presented with sudden-onset right upper quadrant abdominal pain and vomiting. A bedside ultrasound, performed to evaluate hepatobiliary pathology, revealed a normal gallbladder but free intraperitoneal fluid. After an expedited CT and emergent explorative laparotomy, the patient was diagnosed with a small bowel obstruction with ischemia secondary to midgut volvulus. Though midgut volvulus is rare in adults, delays in definitive diagnosis and management can result in bowel necrosis. Importantly, an emergency physician must be able to recognize bedside ultrasound findings associated with acutely dangerous intrabdominal pathology.


Fifty percent of midgut volvulus cases present within the first month of life, and 90% in the first year.[1] After three months, malrotation with midgut volvulus is considered rare.[2] Midgut volvulus begins with incomplete embryologic midgut rotation or fixation. Later the bowel can twist, leading to obstruction of the bowel and its mesenteric blood supply.[3] Typically, midgut volvulus presents with sudden onset abdominal pain with bilious vomiting in the neonate.[4] It can progress to peritonitis, bowel necrosis, shock, and death.[3] In this adult patient, a similar presentation initially led to a work-up for gallbladder pathology, which revealed unexpected red flags for dangerous pathology and led to expedited care. A delay in diagnosis may have ultimately resulted in bowel infarction and death.