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| CASE REPORT |
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| Year : 1997 | Volume
: 43
| Issue : 2 | Page : 46-7 |
Gastric volvulus in childhood.
TP Karande, SN Oak, SJ Karmarkar, BK Kulkarni, SS Deshmukh
Department of Paediatric Surgery, L.T.M.G. Hospital & Medical College, Sion, Mumbai.
Correspondence Address:
T P Karande
Department of Paediatric Surgery, L.T.M.G. Hospital & Medical College, Sion, Mumbai.
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 0010740719 
Gastric volvulus is an uncommon condition more so in the paediatric age group. The cause of gastric volvulus may be idiopathic or secondary to various congenital or acquired conditions. In this short series of three patients, one had volvulus which was due to ligamentous laxity and mobile spleen, second had congenital postero-lateral diaphragmatic defect and the third had hiatus hernia.
Keywords: Case Report, Child, Ehlers-Danlos Syndrome, complications,Female, Gastrostomy, Hernia, Diaphragmatic, congenital,surgery,Hernia, Hiatal, congenital,surgery,Human, Infant, Intestinal Obstruction, etiology,radiography,surgery,Male, Stomach Diseases, etiology,radiography,surgery,
How to cite this article:
Karande T P, Oak S N, Karmarkar S J, Kulkarni B K, Deshmukh S S. Gastric volvulus in childhood. J Postgrad Med 1997;43:46 |
Gastric volvulus is a rare condition. Over 300 cases have been reported since Berti first recognised this condition in 1866, most of these were in adults[1]. Review of literature has revealed 116 cases in infants and children upto 1994[2]. In this condition, acquired torsion of stomach results in partial or complete obstruction of its openings and interruption of the blood supply. Early diagnosis & prompt surgical intervention are required to avoid possible complications.
An 11 year old male patient presented with history of acute abdominal pain and upper abdominal distension of one day duration. Patient was in shock and had visible epigastric distension. X-ray abdomen showed a large fundic gas shadow with hardly any gas going distally and hairpin sign suggestive or volvulus [Figure - 1]. On passing a nasogastric tube, stomach was deflated after aspirating 700cc of clear gastric content. Barium meal was typical of gastric volvulus with pylorus up and fundus down. On gastroscopy, gastric wall was found to be oedematous and scope could not be maneuvered to the pylorus.
On exploration, compound, anterior, complete gastric volvulus was revealed. Stomach was large and distended, short gastrics and gastrosplenic ligament absent and spleen mobile. Fundopexy and anterior gastropexy with gastrostomy was done. Patient recovered with no further gastrointestinal complaints. Since the patient had associated findings of hypermobility of joints, high arched palate, skin extensibility, bilateral congential talipes equinus varus and associated cardiac disease in form of aortic and mitral regurgitation, genetic evaluation was done and he was diagnosed to have Ehler-Danlos syndrome [Figure - 2]. Presence of this syndrome makes case still rarer.
Five month old male child presented with acute onset of abdominal pain and nonbilious vomiting for two days. Patient had tachypnoea and tachycardia. Abdomen was soft and non-tender with mild fullness in epigastrium and left hypochondrium. X-ray chest and abdomen showed elevation of diaphragm. Stomach was seen in the thorax with no gas going distally suggestive of gastric outlet obstruction. Exploration showed left postero-lateral diaphragmatic hernia with sac. Spleen and stomach had herniated up with organo-axial volvulus of stomach. Bands of Ladd were seen suggestive of malrotation. Repair of congenital diaphragmatic hernia with Ladd’s procedure was done. Recovery was uneventful.
Five month old female child weighing 4 kg came with history of failure to thrive and repeated vomiting after feeds and history of epigastric distention on and off after feeds. X-ray chest showed stomach in the thorax and nasogastric tube seen curled within it. Dye study confirmed the finding of hiatus hernia. Exploration revealed hiatus hernia with stomach in thorax with volvulus. Untwisting of gastric volvulus followed by repair of hiatal defect and gastropexy was done.
Gastric volvulus is defined as an abnormal degree of rotation of one part of the stomach around another[3]. The normal stomach is fixed and prevented from abnormal rotation by the four gastric ligaments. A normal diaphragm also serves to prevent abnormal displacement of abdominal viscera and gastric volvulus. Ligamentous laxity, pyloric obstruction leading to chronic gastric dilatation, hiatus hernia, other diaphragmatic hernias, eventration of diaphragm, adhesions serve as predisposing factors for volvulus of stomach. A tight wrap after Nissen’s fundoplication is known to lead to the complication of gastric volvulus[4].
The clinical symptoms depend on the extent or degree of rotation and obstruction in acute gastric volvulus. Time and need of surgical intervention is always determined by the evidence of vascular compromise. Severe epigastric pain and distension, violent unproductive retching and inability to pass a nasogastric tube comprises the classical triad of Borchardt[5]. The features result from obstruction at the cardia and/or pylorus. Sawaguchi has attributed vomiting in young infants to the maldevelopment of hiatal function[6]. Intermittent or chronic gastric volvulus may cause diverse gastrointestinal symptoms in children.
The radiological findings are specific in acute and secondary gastric volvulus. Plain film in chronic volvulus shows only gaseous dilatation of the stomach and intestines. In the case of mesenteroaxial volvulus, gastric shadow may show double air fluid levels in erect position, one in the fundus and the other in the antrum. In organoaxial type, the stomach lies rather horizontally on plain film with single fluid level. The contrast roentgenogram shows a rotated stomach but no obstruction in the case of chronic gastric volvulus. Hence the radiological examination should be done in supine as well as in upright position. Absence of classical roentgen signs of gastric volvulus may be observed in intermittent obstruction.
Acute gastric volvulus is a surgical emergency as delay in recognition and treatment can cause strangulation and perforation of stomach. Chronic volvulus however should be initially treated conservatively by keeping the patient in the prone position. Gastroscopic decompression for chronic gastric volvulus is also reported[7]. Anterior gastropexy supplemented with a gastrostomy is a satisfactory solution to this life threatening problem. Percutaneous gastrostomy using anchoring devices[8] and laparoscopic guided gastropexy[9] are newer modalities reported.
In this short series, patient who had gastric volvulus associated with hiatus hernia underwent untwisting of gastric torsion and repair of hiatal defect, whereas the other patient having left postero-lateral congenital diaphragmatic defect was repaired with nonabsorbable sutures. The third patient developed acute on chronic obstruction in gastric volvulus; laparotomy revealed mobile spleen. Anterior gastropexy and gastrostomy led to a satisfactory recovery.
| :: References | |  |
| 1. |
Berti A. Sigolare altorti glamento dell esofagocol dudeno segitto da rapida morte. Gazz Med Ital Prov Ver 1866; 9:139.  |
| 2. | Amin M, El-Gohary, Atif Etiaby. Gastric volvulus in infants and children. Paed Surg Int 1994; 9:486-488. |
| 3. | Tanner NC. Chronic and recurrent volvulus of the stomach. Am J Surg 1968; 115:505-515. |
| 4. | Kam Pui Fung. Gastric volvulus complicating Nissen’s fundoplication. J Pediatr Surg 1990; 25:1242-1243. |
| 5. | Borchardt M. Kur Pathologie and Therapie des magen volvulus. Arch Kin Chir 1904; 74:243-260. |
| 6. | Sawaguchi S, Ohkawa H. Kanmotsutt: Idiopathic gastric volvulus in infancy and childhood. Z. Kinderchir 1981; 32:218-233. |
| 7. | Bhasin DK, Nagi B, Kochhar R. Endoscopic management of chronic organoaxial volvulus of the stomach. Am J Gastroenterol 1990; 85:1486-1488. |
| 8. | Wu TK, Pietrocola D, Welch HK. New method of percutaneous gastrostomy using anchoring devices. Am J Surg 1987; 153:230-232. |
| 9. | Cameron BH, Blair GK. Laparoscopic guided gastropexy for intermittent gastric volvulus. J Pediatr Surg 1993; 28:1628-1629.
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Figures
[Figure - 1], [Figure - 2]
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