On the basis of the history, clinical examinations and x-ray abdomen, a provisional diagnosis of acute gastric volvulus was made. A decision for immediate exploration was taken. Blood was arranged and written consent was taken from parents for surgical exploration. Through supraumbilical transverse laparotomy incision a hugely distended stomach with greater curvature lying superiorly, was identified. The stomach was gently pulled out and derotated thus placing the greater curvature down to its original position. As soon as the stomach was placed in normal position the nasogastric aspirate increased and stomach got decompressed. There were ischemic patches over the anterior surface of stomach and the fundus which were left as such (Fig. ​(Fig.2,2, ​,3).3). On further exploration of abdomen malrotation was found with duodeno-jejunal junction ( DJ) on right of midline, mobile cecum and presence of Ladd’s band. The Ladd’s procedure was done to correct the malrotation. There was no diaphragmatic defect and spleen was placed in its normal position. Due to ischemia of the stomach fundoplication and gastropexy were not attempted.

The gastric volvulus can be primary which is the result of either absence or laxity of various ligaments attaching the stomach to the surrounding structures. The secondary gastric volvulus can occur due to various anatomic defects like diaphragmatic hernia, malrotation of gut, asplenia, wandering spleen, pyloric stenosis, traumatic injury to diaphragm, phrenic nerve palsy, abdominal tumors etc [3, 4, 5, 6, 7]. In our case, acute gastric volvulus was secondary to malrotation of gut. We hypothesize that partial duodenal obstruction might result in gastric over-distension that predispose to an abnormal rotation of stomach around its long axis.

The gastric volvulus may present as acute surgical emergency or with chronic intermittent symptoms. In acute gastric volvulus there is sudden upper abdominal distension associated with pain abdomen. Patient may present with retching as well. In adults the classical Borchardt’s triad may be found which include sudden pain in abdomen, non productive retching and inability to pass NG tube. In case of chronic gastric volvulus the abdominal pain and distension is intermittent as the stomach derotates itself at times. Early satiety and fullness after meal may be the symptoms [1, 3, 5].

Both plain and contrast radiographs of abdomen play vital role in diagnosis of gastric volvulus. Plain x-ray abdomen shows typical large air fluid level at the left upper quadrant with paucity of distal gas shadows in organoaxial rotation; similar was found in our case. The barium study is more specific as it can show the position of greater curvature, pylorus and the antrum if done with stomach in twisted state [3].

Acute gastric volvulus is a surgical emergency. The delay in the diagnosis and management may result in serious complications like gastric necrosis, gastric perforation, sepsis and cardiovascular failure [6]. In our case the gastric ischemia had occurred however the stomach was viable after derotation.