BMJ 2014;348:g2020 doi: 10.1136/bmj.g2020 (Published 10 March 2014)
Page 1 of 1
Letters
LETTERS INTESTINAL MALROTATION AND VOLVULUS
Infants with suspected intestinal malrotation or volvulus are not prioritised for transfer 1
1
Syed M Mohinuddin consultant neonatologist , Nandiran Ratnavel consultant neonatologist , Ajay 12 K Sinha consultant neonatologist and honorary senior lecturer London Neonatal Transfer Service, Royal London Hospital, Barts Health NHS Trust, London E1 1BB, UK; 2Blizard Institute, Centre for Paediatrics, Barts and the London School of Medicine and Dentistry, London, UK 1
Intestinal malrotation and volvulus in infants can be easily missed. The authors highlight the substantial risk of mortality and morbidity and recommend immediate surgical referral.1 In our experience as a regional neonatal transfer service for London, despite recognition of risks in infants with bilious vomiting, they are not prioritised for transfer to surgical centres.
We recently audited 163 term infants with bilious vomiting transferred at ≤7 days of age. Twenty (12%) of 163 babies had a diagnosis of malrotation or volvulus (or both). The principal diagnoses in these infants were malrotation (7), malrotation with volvulus (6), volvulus (5), and volvulus with atresia (2). Other causes of bilious vomiting in our series were intestinal atresia or stenosis (22), Hirschprung’s disease (19), other surgical causes (18), and sepsis (6). No obvious cause was found in 78 infants. We found no significant associations between clinical findings at the time of transfer in infants subsequently diagnosed as having malrotation or volvulus compared with those with bilious vomiting owing to other causes (abdominal distension (χ2=0; P=0.98), feel of the abdomen (χ2=1.6; P=0.20), abdominal tenderness (χ2=0.3; P=0.58) and abnormal appearance on abdominal radiography (χ2=0.2; P=0.62)).
To assess whether these infants were prioritised appropriately for transfer, we analysed the time from referral to dispatch of a transfer team. The median (range) dispatch time was 31 (0-648) min, which was similar to infants with bilious vomiting related to other causes (31 (0-800) min). Six of 20 infants with malrotation or volvulus had a dispatch time of greater than 60 min.
Our data show a delay in the transfer of these infants even after recognition of the need for surgical evaluation and that it is not possible to reliably differentiate between those with or without malrotation or volvulus. Currently, the UK Neonatal Transport Group does not include infants with bilious vomiting in the time critical transfer category. If not prioritised, these infants remain at risk of developing serious complications despite recognition of symptoms. Competing interests: None declared. Full response at: www.bmj.com/content/347/bmj.f6949/rr/688089. 1
Shalabi MS, Kuti K, Walker G. Intestinal malrotation and volvulus in infants and children. BMJ 2013;347:f6949. (26 November.)
Cite this as: BMJ 2014;348:g2020 © BMJ Publishing Group Ltd 2014
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
Page 1 of 1
Letters
LETTERS INTESTINAL MALROTATION AND VOLVULUS
Infants with suspected intestinal malrotation or volvulus are not prioritised for transfer 1
1
Syed M Mohinuddin consultant neonatologist , Nandiran Ratnavel consultant neonatologist , Ajay 12 K Sinha consultant neonatologist and honorary senior lecturer London Neonatal Transfer Service, Royal London Hospital, Barts Health NHS Trust, London E1 1BB, UK; 2Blizard Institute, Centre for Paediatrics, Barts and the London School of Medicine and Dentistry, London, UK 1
Intestinal malrotation and volvulus in infants can be easily missed. The authors highlight the substantial risk of mortality and morbidity and recommend immediate surgical referral.1 In our experience as a regional neonatal transfer service for London, despite recognition of risks in infants with bilious vomiting, they are not prioritised for transfer to surgical centres.
We recently audited 163 term infants with bilious vomiting transferred at ≤7 days of age. Twenty (12%) of 163 babies had a diagnosis of malrotation or volvulus (or both). The principal diagnoses in these infants were malrotation (7), malrotation with volvulus (6), volvulus (5), and volvulus with atresia (2). Other causes of bilious vomiting in our series were intestinal atresia or stenosis (22), Hirschprung’s disease (19), other surgical causes (18), and sepsis (6). No obvious cause was found in 78 infants. We found no significant associations between clinical findings at the time of transfer in infants subsequently diagnosed as having malrotation or volvulus compared with those with bilious vomiting owing to other causes (abdominal distension (χ2=0; P=0.98), feel of the abdomen (χ2=1.6; P=0.20), abdominal tenderness (χ2=0.3; P=0.58) and abnormal appearance on abdominal radiography (χ2=0.2; P=0.62)).
To assess whether these infants were prioritised appropriately for transfer, we analysed the time from referral to dispatch of a transfer team. The median (range) dispatch time was 31 (0-648) min, which was similar to infants with bilious vomiting related to other causes (31 (0-800) min). Six of 20 infants with malrotation or volvulus had a dispatch time of greater than 60 min.
Our data show a delay in the transfer of these infants even after recognition of the need for surgical evaluation and that it is not possible to reliably differentiate between those with or without malrotation or volvulus. Currently, the UK Neonatal Transport Group does not include infants with bilious vomiting in the time critical transfer category. If not prioritised, these infants remain at risk of developing serious complications despite recognition of symptoms. Competing interests: None declared. Full response at: www.bmj.com/content/347/bmj.f6949/rr/688089. 1
Shalabi MS, Kuti K, Walker G. Intestinal malrotation and volvulus in infants and children. BMJ 2013;347:f6949. (26 November.)
Cite this as: BMJ 2014;348:g2020 © BMJ Publishing Group Ltd 2014
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
