Gastric volvulus is a significant, rare cause of non-bilious vomiting and consists of a pathological rotation of the stomach of more than 180° around the axis without obstruction of the gastrointestinal tract. A definitive diagnosis is made with upper radiological gastrointestinal studies. Treatment may be conservative or surgical with anterior and fundal gastropexy in patients with ingravescent symptoms. We describe the case of a 16-month-old female admitted to our hospital for recurrent and postprandial vomiting episodes which had started at 11 months of age. A history of gastroesophageal reflux was present until 1 year of age, in association with recurrent respiratory infections. The basic metabolic panel was normal. Barium study showed stomach rotation along a horizontal plane stomach. Esophagogastroduodenoscopy showed no mucosal alterations. The diagnosis was chronic organoaxial gastric volvulus. In our patient, the surgical procedure of gastropexy, both anterior and fundal, without fundoplication was performed. She showed good improvement after surgery, with resolution of symptoms and weight gain.
Postprandial vomiting; Chronic gastric volvulus; Anterior; fundal gastropexy
An 80-year-old male patient with a history of a hiatus hernia presented with acute abdominal pain and vomiting. CT of his abdomen revealed extraluminal free gas consistent with a perforation. He had a large hiatus hernia. The subdiaphragmatic portion of the stomach was distended and adopted a more transverse lie. The radiological findings were in keeping with acute gastric volvulus with secondary ischaemic complications. Acute gastric volvulus is an abnormal rotation of the stomach resulting in complete obstruction. It is a surgical emergency and does not always present in its classical form. Clinicians should be mindful of this diagnosis in patients presenting with an acute surgical abdomen, especially if the presentation is non-specific, as delays in diagnosis are associated with significant morbidity and mortality.
Plain radiography and contrast radiologic studies are traditionally the main options in evaluating neonates presenting with bilious vomiting. While ultrasonography (US) is more available, its diagnostic accuracy is in question.
The purpose of this study is to determine the diagnostic accuracy of US in evaluating these patients with bilious vomiting.
Patients and Methods
All neonates with bilious vomiting or bilious nasogastric tube drainage presented to a children’s hospital in a 1.5-year period were included. US were performed in all patients. The results were compared with clinical and radiological data and the final diagnosis. We used chi-square and Fisher’s exact tests for analysis.
The cause of bilious vomiting for 18 of the 23 included patients was surgical. All patients labeled as surgical candidates by US ended in surgery [positive predictive value (PPV) = 100%], while only 50% of the patients with inconclusive US were operated [negative predictive value (NPV) = 50%, Confidence Interval (CI) 95%: 29%-71%]. The sensitivity and specificity of US in diagnosing intestinal atresia (n = 9) was 89% [CI 95%: (68% - 100%)] and 100%. In cases with malrotation (n = 4) and midgut volvulus (n = 2), sonographic diagnosis was in concordance with final surgical diagnosis.
This study suggested that in cases in which US makes a certain diagnosis, its accuracy eliminates the need for further diagnostic tests, but if it is inconclusive, further radiological contrast studies should be tried to make the final diagnosis.
Ultrasonography; Vomiting; Infant, Newborn; Bilious
Between 1984 and 1994, 10 neurologically normal children between 2 and 24 months were diagnosed as having gastric volvulus with associated gastro-oesophageal reflux (GOR). The common features at presentation were episodic colicky abdominal pain, non-bilious vomiting, upper abdominal distension, haematemesis, and failure to thrive. Anterior gastropexy and conservative management of GOR was curative.
A 70-yr-old woman complained of left sided chest pain and non-bilious vomiting for four days after taking a gastric bloating agent for an upper gastrointestinal study. The chest radiography revealed gastric air-fluid levels and bowel loops in the left thoracic cavity. An emergency thoracotomy was performed. The abdominal organs (stomach, spleen, splenic flexure of the colon) were in the left thorax and the entire left hemidiaphragm was absent. There were no diaphragmatic remnants visible for reconstruction of the left diaphragm. We provided warm saline irrigation and performed a left lower lobe adhesiotomy. Thirteen days after surgery, the chest radiography showed improvement in the herniation but mild haziness remained at the left lower lung field. Here we present the oldest case of congenital diaphragmatic agenesis presenting with transient gastric volvulus and diaphragmatic hernia.
Congenital Hemidiaphragmatic Agenesis; Mesenteroaxial Gastric Volvulus; Hernia, Diaphragmatic; Spontaneous Resolution
Chimpanzees (Pan troglodytes) know what others can and cannot see in a competitive situation. Does this reflect a general understanding the perceptions of others? In a study by Hare et al. (2000) pairs of chimpanzees competed over two pieces of food. Subordinate individuals preferred to approach food that was behind a barrier that the dominant could not see, suggesting that chimpanzees can take the visual perspective of others. We extended this paradigm to the auditory modality to investigate whether chimpanzees are sensitive to whether a competitor can hear food rewards being hidden. Results suggested that the chimpanzees did not take what the competitor had heard into account, despite being able to locate the hiding place themselves by the noise.
Social cognition; Food competition; Perspective taking
Gastric volvulus is a rare disease with an unknown incidence. Unless it stays in the back of the diagnostician's mind, diagnosis of gastric volvulus, which can have significant morbidity and mortality associated with it, can be easily missed. Unstable vital signs and distressed appearance are not always present, as in textbook cases. The presence of a hiatal hernia with persistent vomiting despite initial antiemetic treatment should trigger one to think of gastric volvulus, despite the patient appearing very stable. With the advent of CT and laparoscopic surgery, the gold standards for diagnosing and treating this disease are ever evolving.
An eighteen-month-old boy who had undergone a Ladd's procedure for malrotation in the newborn period presented with acute onset of nausea, vomiting, rectal bleeding, and confusion. Laparotomy revealed midgut volvulus, mesenteric lymphadenopathy and massive chylous ascites. Recurrent midgut volvulus following Ladd's procedure is extremely rare but should be borne in mind in cases of persistent or recurrent gastrointestinal symptoms. Timely surgery is necessary to avoid intestinal gangrene and decrease morbidity and mortality related to consequences of midgut volvulus.
Intestinal malrotation; Midgut volvulus, recurrent
Abdominal pain with bilious emesis is an ominous clinical presentation with many possible causes. We describe a previously healthy 4-year-old boy who presented with these symptoms and ultrasound findings of fluid throughout most of the abdominal cavity. Computed tomography imaging revealed a large cystic mass (21-by-13 cm) associated with a small bowel obstruction due to volvulus. A laparoscopic exploration was undertaken, revealing a large mass arising from the small intestinal mesentery and causing a segmental volvulus of the small bowel. Conversion to mini-laparotomy allowed reduction of the volvulus and segmental resection of the small bowel associated with a giant mesenteric lymphatic malformation. This case describes a rare cause of intestinal volvulus due to a mesenteric lymphatic malformation.
A human being is a complex entity consisting of the Self (also known as Consciousness), mind, senses and the body. The Vedānta tradition holds that the mind, the senses and the body are essentially different from the Self or Consciousness. It is through consciousness that we are able to know the things of the world, making use of the medium of the mind and the senses. Furthermore, the mind, though material, is able to reveal things, borrowing the light from consciousness. From the phenomenological point of view, we have to answer the following questions: how does one know the mind/the mental operations/the cogitations of the mind? Does the mind know itself? Is it possible? There is, again, the problem of the intentionality of consciousness. Is consciousness intentional? According to Vedānta, consciousness by its very nature is not intentional, but it becomes intentional through the mind. The mind or the ego is not part of the consciousness; on the contrary, it is transcendent to consciousness. It is difficult to spell out the relation between consciousness and the mind. How does consciousness, which is totally different from the mind, get related to the mind in such a way that it makes the latter capable of comprehending the things of the world? The Vedānta tradition provides the answer to this question in terms of the knower-known relation. Consciousness is pure light, self-luminous by its very nature, that is, although it reveals other objects, it is not revealed by anything else. When Sartre describes it as nothingness, bereft of even ego, it is to show that it is pure light revealing objects outside it.
Consciousness; Self; Vedānta tradition; Mind; Self; Intentionality; Sartre; Śankara; Popper; Husserl; Enworlded subjectivity
Metastatic breast cancer to the small bowel (SB) presenting as gallstone ileus and resulting in SB obstruction has not been described previously. A 76-year-old woman with previous metastatic breast cancer to the axial spine and hips presented with abdominal pain and bilious vomiting. CT scanning revealed SB obstruction consistent with gallstone ileus. The patient underwent two segmental SB resections for distal ileal strictures mimicking what appeared to be macroscopic Crohn's disease. The entero-biliary fistula was undisturbed. Pathological analysis revealed the dual pathologies of gallstone ileus and metastatic carcinoma from a breast primary causing luminal SB obstruction. Improvements in staging and treatment modalities have contributed to the increased overall long-term survival for breast cancer, compelling clinicians to consider metastatic breast cancer as a differential diagnosis in women presenting with new onset of gastrointestinal symptoms in order that appropriate treatment be administered in a timely fashion.
Arrow injuries are an extinct form of injury in most parts of the developed world, but are still seen, albeit infrequently in developing countries. Reports of penetrating injuries of the craniofacial region secondary to projectiles are few and far between. The morbidity-free outcome of surgical removal, in case of penetrating arrow injuries, despite the delay in presentation and, moreover, in the emergency surgical practice, are the salient points to be remembered whilst managing such cases, for ‘what the mind knows is what the eyes see and what the eyes see is what can be practiced’. We report the case of a patient who was attacked by a projectile fired from a crossbow. Immediate surgery under general anesthesia was required to remove the arrow, with utmost care to avoid any neurovascular compromise to the facial nerve, as well as minimize postoperative complications such as otitis media and subsequent meningitis.
Arrow injury; craniofacial injury; meningitis
Intestinal malrotation in the newborn is usually diagnosed after signs of intestinal obstruction, such as bilious emesis, and corrected with the Ladd procedure.
The objective of this report is to describe the presentation of severe cases of midgut volvulus presenting in infancy, and to discuss the characteristics of these cases.
We performed a seven year review at our institution and present two cases of catastrophic midgut volvulus presenting in the post-neonatal period, ending in death soon after the onset of symptoms. These two patients also had significant laboratory abnormalities compared to patients with more typical presentations resulting in favorable outcomes.
While most cases of intestinal malrotation in infancy can be treated successfully, in some circumstances, patients’ symptoms may not be detected early enough for effective treatment, and therefore may result in catastrophic midgut volvulus and death.
Malrotation; midgut volvulus; neonatal intensive care
Gastric volvulus, organoaxial or mesenterioaxial, is a rare condition in infancy and childhood. We experienced 7 cases of pediatric gastric volvulus, consisting of 3 cases of secondary gastric volvulus due to left diaphragmatic eventration or paraesophageal hernia and 4 cases of idiopathic gastric volvulus. Of 7 cases, five were organoaxial in type and two were mesenterioaxial. The main symptoms of secondary gastric volvulus were vomiting and respiratory difficulty whereas those of idiopathic gastric volvulus were abdominal distension and weight loss with or without failure to thrive. It may be suspected on plain abdominal radiographs and usually confirmed by upper gastrointestinal series. Upper gastrointestinal series in organaxial volvulus demonstrated characteristic findings such as reversal of the greater and lesser curvatures and two air-fluid levels. In mesenterioaxial volvulus, the stomach was rotated into inverted position with pyloroantral obstruction showing a beak appearance. The three patients with secondary volvulus underwent repair of associated defect with or without gastropexy and the 3 patients with idiopathic volvulus underwent anterior gastropexy or gastrostomy. In those with idiopathic gastric volvulus, there was no obvious cause such as laxity of the perigastric ligaments. The operative results were satisfactory except for the three patients with idiopathic gastric volvulus whose abdomen remained distended regardless of weight gain.
Internal hernias are a rare cause of bowel obstruction in the neonate and present with bilious vomiting. Newborns may be at risk of loss of significant length of bowel if this rare condition is not considered in the differential diagnosis of bilious emesis.
PRESENTATION OF CASE
We report a case of a twin with an internal hernia through a defect in the ileal mesentery who presented with neonatal bowel obstruction. The patient had a microcolon on the contrast enema suggesting that the likely etiology was an intra-uterine event most likely a vascular accident that prevented satisfactory meconium passage into the colon.
An internal hernia is rarely considered in the differential diagnosis of distal bowel obstruction in a neonate with a microcolon. Congenital trans-mesenteric hernias constitute only 5–10% of internal hernias. True diagnosis of trans-mesenteric hernias is difficult due to lack of specific radiology or laboratory findings to confirm the suspicion.
When clinical and radiological findings are not classical, rare possibilities such as an internal hernia must be considered in the differential diagnosis, to avoid catastrophic bowel loss.
Internal hernia; Congenital mesenteric defect; Neonatal bowel obstruction
AIM: To assess the diagnostic value of a combination of intragastric bile acids and hepatobiliary scintigraphy in the detection of duodenogastric reflux (DGR).
METHODS: The study contained 99 patients with DGR and 70 healthy volunteers who made up the control group. The diagnosis was based on the combination of several objective arguments: a long history of gastric symptoms (i.e., nausea, epigastric pain, and/or bilious vomiting) poorly responsive to medical treatment, gastroesophageal reflux symptoms unresponsive to proton-pump inhibitors, gastritis on upper gastrointestinal (GI) endoscopy and/or at histology, presence of a bilious gastric lake at > 1 upper GI endoscopy, pathologic 24-h intragastric bile monitoring with the Bilitec device. Gastric juice was aspirated in the GI endoscopy and total bile acid (TBA), total bilirubin (TBIL) and direct bilirubin (DBIL) were tested in the clinical laboratory. Continuous data of gastric juice were compared between each group using the independent-samples Mann-Whitney U-test and their relationship was analysed by Spearman’s rank correlation test and Fisher’s linear discriminant analysis. Histopathology of DGR patients and 23 patients with chronic atrophic gastritis was compared by clinical pathologists. Using the Independent-samples Mann-Whitney U-test, DGR index (DGRi) was calculated in 28 patients of DGR group and 19 persons of control group who were subjected to hepatobiliary scintigraphy. Receiver operating characteristic curve was made to determine the sensitivity and specificity of these two methods in the diagnosis of DGR.
RESULTS: The group of patients with DGR showed a statistically higher prevalence of epigastric pain in comparison with control group. There was no significant difference between the histology of gastric mucosa with atrophic gastritis and duodenogastric reflux. The bile acid levels of DGR patients were significantly higher than the control values (Z: TBA: -8.916, DBIL: -3.914, TBIL: -6.197, all P < 0.001). Two of three in the DGR group have a significantly associated with each other (r: TBA/DBIL: 0.362, TBA/TBIL: 0.470, DBIL/TBIL: 0.737, all P < 0.001). The Fisher’s discriminant function is followed: Con: Y = 0.002TBA + 0.048DBIL + 0.032TBIL - 0.986; Reflux: Y = 0.012TBA + 0.076DBIL + 0.089TBIL - 2.614. Eighty-four point zero five percent of original grouped cases were correctly classified by this method. With respect to the DGR group, DGRi were higher than those in the control group with statistically significant differences (Z = -5.224, P < 0.001). Twenty eight patients (59.6%) were deemed to be duodenogastric reflux positive by endoscopy, as compared to 37 patients (78.7%) by hepatobiliary scintigraphy.
CONCLUSION: The integrated use of intragastric bile acid examination and scintigraphy can greatly improve the sensitivity and specificity of the diagnosis of DGR.
Duodenogastric reflux; Diagnosis; Intragastric bile acids; Hepatobiliary scintigraphy
Because the clinical appearance of newborn infants having intestinal obstruction is disarmingly normal, vomiting is reason for immediate search for the cause. To this end the character of stools and meconium that are passed should be carefully observed, lest valuable time elapse before correct diagnosis is made.
In three cases of volvulus observed by the authors, there was moderate to pronounced distention of the abdomen at birth—a sign which may be helpful in diagnosis.
Roentgenograms are the most helpful diagnostic aid. Since the roentgenographic appearance of the normal infant abdomen differs from that of the adult, interpretations should be made with that in mind. In this connection the absence of gas shadows is significant. Although there are dangers in the use of barium in infants, early diagnosis is so important that use of the substance is justifiable if it will help in correct appraisal.
The treatment is always surgical, and the procedure of choice is primary anastomosis. Proper preoperative and postoperative care and treatment, including maintenance of fluid and electrolyte balance and blood volume, are of great importance.
Did you visit the Neuronus conferences in the years 2012 and 2013 in Kraków?
If not, then you certainly should have a close examination of this special issue
including this introduction to at least have a glimpse of an idea of the highly
interesting topics in the field of cognitive neuroscience that were presented at
these conferences. If you were there, it is for sure a good choice to focus on
this special issue as well, first to refresh your minds (we know our memories
are far from perfect), but especially to see what happened with research of the
presenters at these conferences.
right ear advantage; attention; EEG; beta band; visual word form area; disorders of consciousness; functional connectivity; default mode network; DTI; structural connectivity; MUC model; N400; neural oscillations; schizophrenia; insight; sleep; social cognition; lateralized power spectra; motion-based Simon effect; reaction time distribution; Adolf Beck
Mesenteroaxial volvulus is a form of gastric volvulus that rotates around the short axis of the stomach. Mesenteroaxial volvulus typically presents secondary to an anatomical defect with symptoms that include epigastric pain, retching, dysphagia and early satiety. Our patient presented with episodic abdominal pain, nausea and vomiting for 2 years. Previous imaging was unremarkable but an esophagogastroduodenoscopy done when the patient most recently presented with abdominal pain revealed a mesenteroaxial volvulus. He underwent a laparoscopic gastrostomy-tube gastropexy and has not had any recurrence of his symptoms to date. This case illustrates the difficulties in diagnosing an intermittent volvulus as untimely imaging of a temporarily unfolded volvulus can delay diagnosis and treatment.
Colonic obstruction due to sigmoid colon volvulus during pregnancy is a rare but complication with significant maternal and fetal mortality. We describe a case of sigmoid volvulus in a patient with 33 weeks of gestation that developed complete necrosis of the left colon. Case. 27-year-old woman was admitted with 3 days of abdominal distention, vomit, and the stoppage of the passage of gases and feces. She was admitted with poor clinical conditions with septic shock, acute respiratory distress syndrome, and signs of diffuse peritonitis. Abdominal radiography showed severe dilation of the colon with horseshoe signal suggesting a sigmoid volvulus, pneumoperitoneum and we could not we could not identify fetal heartbeats. With a diagnosis of complicate sigmoid volvulus she was underwent to the laparotomy where we found necrosis of all descending colon due to double twist volvulus of the sigmoid. We performed a colectomy with a confection of a proximal colostomy, and closing of the rectal stump. Due to an uncontrollable uterine bleeding during cesarean due, it was required a hysterectomy. The patient had an uneventful postoperative course thereafter and was discharged on a regular diet on the 15th postoperative day.
Some of my pregnant patients have trouble functioning because of morning sickness. In particular, they are afraid to take medications. They end up losing weight, quitting work, and dropping out of other activities. What can I do to allay their fears?
Women often benefit from knowing that they are not alone in having this problem, that morning sickness typically does not harm a fetus, and that safe therapies are available. Psychological and medical support is very important. Other causes of nausea and vomiting must always be ruled out. The Motherisk Program has a clinic and hot-line line for patients with severe morning sickness.
An analyst has to display all the patience and
tolerance and reliability of a mother devoted
to her infant, has to recognize the patient’s
wishes as needs, has to put aside other interests in order to be available and to be punctual, and objective, and has to seem to want
to give what is really only given because of the
There may be a long initial period in
which the analyst’s point of view cannot be
(even unconsciously) appreciated by the patient. Acknowledgment cannot be expected
because at the primitive root of the patient
that is being looked for there is no capacity
for identification with the analyst, and certainly the patient cannot see that the analyst’s
hate is often engendered by the very things
the patient does in his crude way of loving.
In the analysis (research analysis) or in
ordinary management of the more psychotic
type of patient, a great strain is put on the
analyst (psychiatrist, mental nurse) and it is
important to study the ways in which anxiety
of psychotic quality and also hate are produced in those who work with severely ill
psychiatric patients. Only in this way can
there be any hope of the avoidance of therapy
that is adapted to the needs of the therapist
rather than to the needs of the patient.
Gastric volvulus is an uncommon clinical entity, first described by Berti in 1866. It is a rotation of all or part of the stomach through more than 180°. This rotation can occur on the longitudinal (organo-axial) or transverse (mesentero-axial) axis. This condition can lead to a closed-loop obstruction or strangulation. Traditional surgical therapy for gastric volvulus is based on an open approach. Here we report the case of a patient with chronic intermittent gastric volvulus who underwent a successful laparoscopic treatment.
A 34-year-old woman presented with multiple episodes of recurrent upper abdominal pain associated with retching and vomiting, treated unsuccessfully with intramuscular metoclopramide. Endoscopic examination of the upper digestive tract showed a suspected rotation of the stomach, and a chronic recurrent gastric volvulus was revealed by barium meal. The patient was operated on successfully, with an anterior laparoscopic gastropexy performed as the first surgical approach.
Experience with laparoscopic anterior gastropexy is limited only to a few described cases. Our patient was clinically and radiologically followed-up for 2 years with no evidence of recurrence, either radiological or symptomatic. Based on this result, laparoscopic gastropexy can be seen and considered as an initial 'gold standard' for the treatment of gastric volvulus.
Gastric volvulus is a rare but potentially life-threatening clinical entity due to possible gastric necrosis. A wandering spleen may also be associated with gastric volvulus. Patients presenting with the triad epigastralgia, vomiting followed by retching, and difficulty or inability to pass a nasogastric tube into the stomach are likely to have gastric volvulus. The operating surgeon should include this rare entity in the differential diagnosis when dealing with a patient with such a clinical profile. Herein, we present a case of gastric volvulus associated with a wandering spleen in a 28-year-old Caucasian woman and we provide a brief review of the literature on this issue.
Gastric outlet obstruction usually presents with non-bilious vomiting, colicky epigastric pain, loss of appetite and occasionally, upper gastrointestinal bleeding. Causes can be classified as benign or malignant, or as extra- or intraluminal. Gastrojejunostomy is a well-recognised surgical procedure performed to bypass gastric outlet obstruction. A bezoar occurs most commonly in patients with impaired gastrointestinal motility or with a history of gastric surgery. It is an intestinal concretion, which fails to pass along the alimentary canal.
A 62-year-old Asian woman with a history of gastrojejunostomy for peptic ulcer disease was admitted to hospital with epigastric pain, vomiting and dehydration. All investigations concluded gastric outlet obstruction secondary to a "stricture" at the site of gastrojejunostomy. Subsequent laparotomy revealed that the cause of the obstruction was a bezoar.
Many bezoars can be removed endoscopically, but some will require operative intervention. Once removed, emphasis must be placed upon prevention of recurrence. Surgeons must learn to recognise and classify bezoars in order to provide the most effective therapy.