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Journal of Case Reports
Acute Mesenteroaxial Gastric Volvulus with Eventration of the Diaphragm
Kamlesh K Tiwari, Chetan Sharma, Vijay Kumar Kundal, Vinita Chaturvedi, Raksha Kundal1, Deen Dayal  Sharma  
From the Department of Paediatric Surgery and Department of Anaesthesia1, S.M.S. Medical College & associated SPMCHI, Jaipur-302004, India.
Corresponding Author:
Dr. Vijay Kumar Kundal
Email: vijayraksha@yahoo.com
Received: 14-OCT-2013 Accepted: 30-NOV-2013 Published Online: 20-DEC-2013
DOI: http://dx.doi.org/10.17659/01.2013.0105
Abstract
We report a 6 year old female child who presented with acute mesenteroaxial volvulus of the stomach associated with eventration of the left hemidiaphragm. Clinically the child presented with epigastric distension, unproductive retching and upper abdominal pain. The patient was diagnosed by upper gastro-intestinal contrast study and was immediately operated with the successful outcome.
Keywords : Diaphragmatic Eventration, Stomach Volvulus, Intestinal Volvulus, Abdominal Pain.
Introduction 

Gastric volvulus is usually a disease occurring more commonly in adults.  10-12% of cases occur before age of 1 year, but cases have been reported in children up to 12 years of age. Gastric volvulus is an abnormal degree of rotation of one part of the stomach around another varying from 180 degree to 360 degrees [1]. According to the axis of rotation of the stomach, it is of three types: organoaxial, mesenteroaxial and combined  type. Rotation of the stomach result in incomplete or complete obstruction at the inlet or outlet associated with vascular compromise. Early diagnosis and surgical intervention is required to prevent grave complications like ischemia, necrosis and perforation. Gastric volvulus may be primary or secondary, depending upon the absence or presence of associated anomalies. Among the associated anomalies diaphragmatic defect is most common predisposing cause for volvulus in upto 60% of the cases [2].  We herein report a successful management of 6 year old female child who presented with acute mesenteroaxial gastric volvulus with eventration of the diaphragm. 

Case Report 

A 6 years old female child presented with sudden onset of non bilious vomiting, upper abdominal pain and epigastric distension for last 24 hours. Initially vomitus contained ingested food but later on she had unproductive retching. There was no history of hematemesis or any significant past history. 

Examination revealed stable vitals with mild pallor, visible fullness seen in epigastric and umbilical region of abdomen.  Abdomen was non tender with absence of guarding and rigidity and there was normal bowel sound pattern. In view of evident upper abdominal distention, nonbilious vomiting and acute abdomen, upper gastro intestinal obstruction was suspected. 1.5 liters of gastric contents were aspirated on placement of nasogastric tube. X-ray abdomen in erect position showed raised left hemidiaphragm with a large air-fluid level in the left hypochondrium, paucity of distal gas and right mediastinal shift [Fig.1]. In view of raised left hemidiaphragm with a large air-fluid level in left sub-phrenic space, eventration of diaphragm with gastric volvulus was suspected. Routine hematological and biochemical tests revealed anemia which was corrected with blood transfusion. 

The diagnosis was confirmed by upper GI contrast study, which showed grossly distended spherical stomach, raised left dome of diaphragm with stomach extending into left thorax, the fundus of stomach lying at lower level and the antrum part at higher level suggestive of inversion of stomach. Dye did not extend beyond the pyloric region suggestive of   obstruction [Fig.2].

After adequate resuscitation the child was taken up for surgery by left subcostal incision.  Intraoperative findings revealed grossly distended stomach. The gastroesophageal junction and fundus of stomach were at a lower level and the antrum at high level leading to confirmation of mesenteroaxial volvulus [Fig.3]. Derotation was made. Spleen and colon were seen high up below the eventrated diaphragm. The plication of diaphragm was done [Fig.4] and then anterior gastropexy was performed with fixing the stomach at two points to the anterior abdominal wall and fundus with the plicated diaphragm. Post operatively, the child was kept nil per orally for 2 days and started oral feeding on 3rd day and was discharged uneventfully on day 7. 






Discussion 

Gastric volvulus is rare because the stomach is held securely in place by four attachments namely esophageal hiatus, gastro-phrenic ligament, gastro-splenic ligament and duodenum which prevent abnormal rotation of the stomach. A normal diaphragm is also responsible for prevention of abnormal displacement of abdominal viscera and gastric volvulus. Abnormalities of these suspensory ligaments of the stomach, or excessive mobility due to wide sub-diaphragmatic space as in eventration of the diaphragm leads to gastric volvulus. Gastric volvulus is of three types: organoaxial, mesenteroaxial and combined types.  In organoaxial or upside-down stomach, rotation occurs along its long axis with greater curvature displaced superior to the lesser curvature. It is most common type in both children and adults and is usually associated with diaphragmatic defects and vascular compromise is more common in this type. In mesenteroaxial volvulus, stomach rotates along its short axis, passing from greater curvature to lesser curvature perpendicular to long axis, with antrum displaced at a higher level to the gastro-esophageal junction as seen in our case, and diaphragmatic defect is less commonly seen. It is more often seen in infants and children, but  Cribbs et al. showed that organoaxial is also more common in this age group as well  (54% vs. 41% mesenteroaxial and 5% combined) [3]. In combined form stomach rotates on both its long and short axis.

The incidence of gastric volvulus is slightly more common in males. The most common presentation is non-bilious vomiting, upper abdominal distension and pain, these symptoms depend on the degree and rapidity of twisting. The typical features include Borchardt’s triad of epigastric pain, retching with no vomiting, and difficulty or failure to pass nasogastric tube associated with acute gastric volvulus [4].  Triad seen in 30% in adult and rarely in children but one or more of these criteria is present in 70% of children suffering from gastric volvulus. Eventration of diaphragm is the most commonly associated anomaly among the congenital or traumatic diaphragmatic hernia, parahiatal hernia, Morgagni hernia, pyloric stenosis, intestinal malrotation, wanderning spleen, and Asplenia-polysplenia syndrome.

Because of low incidence in children, diagnosis requires high degree of suspicion. Upper gastrointestinal contrast study is the procedure of choice to diagnose the condition as it will evaluate the anatomical changes of stomach more exactly as seen in our case. The diagnosis was confirmed by upper GI contrast study, which shows grossly distended spherical stomach, raised left dome of diaphragm with stomach extending into left thorax, the fundus of stomach lying at lower level and the antrum part at higher level  suggestive of inversion of stomach [5].  CT scan, and MRI are another imaging modalities which provide good anatomical details and confirm the diagnosis.

After adequate resuscitation the child was taken up for surgery by left subcostal incision, because it allows ready access to both diaphragm for plication and stomach for gastropexy, and allows abdominal exploration for associated gastrointestinal anomalies [6]. Reduction of acute gastric volvulus may be attempted with nasogastric decompression but it is often unsuccessful, so surgical repair in the form of anterior gastropexy, whether open or laparoscopic assisted is performed to fix the stomach in its anatomically correct position [7]. Most cases of acute and chronic gastric volvulus can now be approached laparoscopically. A combined laparoscopic and endoscopic approach has also been used to better assess the intra-luminal and intra-abdominal status of the stomach as well as its position before, during and after fixation. Surgical goals of treatment include reduction of the volvulus, prevention of recurrence and correction of predisposing factors. Emergent surgical intervention is indicated for acute gastric volvulus but majority of patients with chronic volvulus  are managed non-operatively and surgery is performed to prevent complications. Early diagnosis and treatment ensure excellent prognosis. The overall mortality rates of acute gastric volvulus range from 15% to 20%, while those for chronic gastric volvulus range from 0% to 13% [8].  About  more than 2/3rd of these deaths are due to delay in the management of volvulus leading to complications like  gastric ischemia,  necrosis, perforation, peritonitis, and mediastinitis, all associated with poor prognosis.

Conclusion 

Acute gastric volvulus, although rare in the children, but it does require a heightened sense of awareness to avoid delay in appropriate therapy and minimize the risk of complications which can lead to death.  Gastric volvulus should always be kept in differential diagnosis in a patient with acute abdomen, epigastric distension and non-bilious vomiting so as to help in early diagnosis and prevention of grave complications.

Acknowledgements

The authors gratefully acknowledge the help provided by Achamma KE, Incharge nursing staff in providing vital information & investigations regarding the patient.  

References 
  1. Cameron AEP, Howard ER. Gastric volvulus in childhood. J Pediatr Surg. 1987;22:944-947.
  2. Singal AK, Vignesh KG, Maltthai J. Acute gastric volvulus secondary to eventration of the diaphragm in a child. J Indian Assoc Pediatr Surg. 2006;11:44-46.
  3. Cribbs RK, Gow KW, Wulkan ML. Gastric volvulus in infants and children. Pediatrics. 2008;122:e752-762.
  4. Borchardt M. Zur Pathologie, Therapie des magen volvulus. Arch Klin Chir.1904;74:243–260.
  5. Peterson CM, Anderson JS, Hara AK, Carenza JW, Menias Co. Volvulus of the gastro intestinal tract: Appearance at multimodality Imaging. Radiographic. 2009;29:1281-1293.
  6. Par W, Choi S, Suh S. Pediatric gastric volvulus- Experience with 7 cases. J Korean J Intern Med. 2000;15(2):127-130.
  7. Schleef J, Von Bismarck S. An easy method for laparoscopically assisted percutaneous anterior gastropexy. Surg Endosc. 2000;14:964-965.
  8. Katkhouda N, Mavor E, Achanta K, Friedlander MH, Grant SW, Essani R, et al. Laparoscopic repair of chronic intrathoracic gastric volvulus. Surgery. 2000;128:784-790.
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Tiwari KK, Sharma C, Kundal VK, Chaturvedi V, Kundal R, Sharma DDAcute Mesenteroaxial Gastric Volvulus with Eventration of the Diaphragm.JCR 2013;3:460-463
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Tiwari KK, Sharma C, Kundal VK, Chaturvedi V, Kundal R, Sharma DDAcute Mesenteroaxial Gastric Volvulus with Eventration of the Diaphragm.JCR [serial online] 2013[cited 2020 Nov 27];3:460-463. Available from: http://www.casereports.in/articles/3/2/Acute-Mesenteroaxial-Gastric-Volvulus-with-Eventration-of-the-Diaphragm.html
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