## Clinical Context Malrotation with midgut volvulus is a surgical emergency in neonates. The 'double bubble' sign on X-ray (dilated duodenum and proximal jejunum) is pathognomonic. Although this infant is currently haemodynamically stable, the risk of bowel necrosis and sepsis is imminent. ## Management Algorithm ```mermaid flowchart TD A[Suspected malrotation with volvulus]:::outcome --> B{Haemodynamic stability?}:::decision B -->|Unstable/peritonitis| C[Immediate OR]:::urgent B -->|Stable| D[NG decompression + IV fluids]:::action D --> E[Urgent surgical consultation]:::action E --> F[Operative planning & consent]:::action F --> G[Ladd's procedure]:::action G --> H[Bowel viability assessed]:::outcome ``` ## Key Point: **Preoperative stabilization is essential but must NOT delay surgery.** NG decompression reduces gastric distension and aspiration risk; IV fluids correct dehydration and electrolyte imbalance. ## High-Yield: - **Ladd's procedure** = division of Ladd's bands, counterclockwise rotation of the midgut, and widening of the mesentery base. This is the definitive surgical fix. - Contrast studies are NOT required when clinical and imaging findings are diagnostic — they delay life-saving surgery. - Even haemodynamically stable neonates with volvulus can deteriorate rapidly as ischaemia progresses. ## Clinical Pearl: The 'double bubble' sign indicates duodenal obstruction (often at the ligament of Treitz due to volvulus). Combined with bilious vomiting in a neonate, this is malrotation until proven otherwise — no further imaging needed. ## Warning: **Do NOT perform contrast studies or prolonged observation.** These delay definitive treatment and increase the risk of transmural necrosis, perforation, and sepsis. 
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