Gastric Volvulus

The clinical presentation of patients with gastric volvulus depends upon the speed of the onset. In 1904 Borchardt described the classic triad of acute or localized distention of the epigastrium associated with pain, inability to pass a nasogastric tube, and nonproductive attempts at vomiting; a recent literature review described 581 cases in infants and children (Coran, 2012).

The presenting symptoms can be intermittent or complete gastric obstruction, ischemia, pain, and/or bleeding. The most common signs and symptoms of gastric volvulus in children include acute abdominal pain, intractable retching, and the inability to pass a nasogastric tube into the stomach lumen (George W., 2014).

The principal symptoms include cyanosis (11%), acute respiratory distress (10%), abdominal pain (34%), non-bilious emesis (75%), and epigastric distention (47%). In contrast to the acute presentation, 75% of chronic volvulus was of primary etiology. The vast majority of chronic cases are organoaxial (85%). Non-bilious emesis remains the most common symptom. Feeding problems or growth failure (30%) was seen more prominently in chronic cases (Coran, 2012). In this case, the symptoms include non-bilious emesis, coughing, chocking and then admitted to the hospital after suffered from the respiratory problem/ pneumonia.

Gastric volvulus is classified according to the plane of rotation. In organoaxial volvulus, the stomach rotates on its long axis; the greater curvature passes anteriorly but may be displaced posteriorly. The less common mesenteroaxial volvulus, rotation is on an axis from greater to lesser curvature (the pylorus or cardia commonly rotates anteriorly). The opposite rotation may also occur. The torsion may be total, involving the entire stomach, or partial, limited to the pyloric end. The rotating section usually passes anteriorly (Coran, 2012) .

Gastric volvulus is a rare condition that is seldom considered in the first as in this case, the patient initially treated with pneumonia for almost 1 month of hospitalization. Further investigation such as esophagus-stomach-duodenum imaging with barium and endoscopy was done and gastric volvulus was identified. The imaging with contrast that held to the patient showed partial mesenteroaxial volvulus, fundus appeared to be rotated toward inferior anteromedial and some fundus in caudal. The part of gatser that rotated was partial, and limited to the fundus of gaster. Therefore, the symptoms are not so typical.

The patient had been coughing and chocking followed by vomiting while breast feeding since the age of 3 months. The reflux of gastric contains could irritate esophagus and surrounding structure including respiratory tract, and in the long term emerged symptoms of pneumonia.

Treatment consists of patient resuscitation, nasogastric decompression, and surgical correction. The volvulus is reduced. Any diaphragmatic defects are repaired in secondary gastric volvulus. A gastropexy is then performed. This has traditionally been accomplished with a gastrostomy tube or button. However, there have been several recent reports of successful laparoscopic gastropexy in which the anterior stomach, along the greater curvature, is sutured to the abdominal wall (George W., 2014).

Reference

Coran, Arnol, Adzick, N. Scott, Krummel, Thomas, Laberge, Jean-Martin, Shamberger, Robert, Caldamone, Anthony. 2012. Peptic Healing and Other Conditions of the Stomach in pediatric Surgery Volume3, Seventh edition. Elsevier: Philadelphia.

Holcom, George W., Murphy, J. Patrick, Ostile, Daniel J. 2014. Lesions of the stomach in Ashcraft’s Pediatric Surgery. Elsevier: Philadelphia

Rashif, F., Thangarajah, T., Mulvey, D., Larvin, M., Iftikhar, S.Y. A review article on gastric volvulus: A challenge to diagnosis and management. International Journal of Surgery 2009;8:18-24.