Cecal volvulus is uncommon in pediatric patients and there are few reports of cecal volvulus with cerebral palsy. Here, we report the case of a 19-year-old male patient who presented with abdominal distension, a history of cerebral palsy, refractory epilepsy due to lissencephaly, and chronic constipation. An abdominal x-ray and computed tomography without contrast enhancement showed fixed dilated bowel intensity in the right lower abdomen. Despite decompression with gastric and rectal tube insertion, symptoms did not improve. The patient underwent an exploratory laparotomy that revealed cecal volvulus. Cecal volvulus usually occurs following intestinal malrotation or previous surgery. In this patient, however, intestinal distension accompanying mental disability and chronic constipation resulted in the development of cecal volvulus. We suggest that cecal and proximal large bowel volvulus should be considered in patients presenting with progressive abdominal distension combined with a history of neuro-developmental delay and constipation.
Cecum; Inteseinal volvulus; Lissencephaly
We report three infants who presented with acute gastric volvulus and recovered initially after de-torsion, but later presented with sequelae due to ischemia of gastroesophageal junction, stomach and gastroduodenal junction. The first two infants could not be fed orally or by gastrostomy tube because of microgastria and stricture of the lower esophagus and gastroduodenal junction, and were managed on jejunostomy feeds, while the third child was managed on gastrostomy feeds till the gastric substitution surgery. The first case was treated nonsurgically with repeated dilatations, but ultimately succumbed to sepsis and malnutrition. In the second child, attempted dilatation resulted in esophageal perforation and she was reconstructed using ileocecal segment as a substitute for stomach and lower esophagus, and has done well. The third child was managed surgically by the Hunt Lawrence J pouch as stomach substitute and has also done well.
Eventration; gastric volvulus; gastroesophageal stenosis
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.
Background and Objectives:
Acute and chronic gastric volvulus usually present with different symptoms and affect patients primarily after the fourth decade of life. Volvulus can be diagnosed by an upper gastrointestinal contrast study or by esophagogastroduodenoscopy. There are three types of gastric volvulus: 1) organoaxial (most common type); 2) mesenteroaxial; and 3) a combination of the two. If undetected or if a delay in diagnosis and treatment occurs, serious complications can develop.
We present four cases of surgical repair of organoaxial volvulus consisting of laparoscopic reduction of the volvulus with excision of the hernia sac and reapproximation of the diaphragmatic crura. A Nissen fundoplication, to prevent reflux, was performed, and the stomach was pexed to the anterior abdominal wall by laparoscopic placement of a gastrostomy tube, thus preventing recurrent volvulus.
There were no operative complications, and all four patients tolerated the procedure well. The patients were discharged one to three days postoperatively and were asymptomatic within two months.
With the advancement of laparoscopic Nissen fundoplication and laparoscopic repair of paraesophageal and hiatal hernias, minimally invasive surgical repair is possible. Based on our experience, we advocate the laparoscopic technique to repair gastric volvulus.
Laparoscopy; Volvulus; Gastric volvulus
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.
Acute intrathoracic gastric volvulus occurs when the stomach undergoes organoaxial torsion in the chest due to either concomitant enlargement of the hiatus or a diaphragmatic hernia. Iatrogenic diaphragmatic hernia can occur after hiatal hernia repair and other surgical procedures, such as nephrectomy, esophagogastrectomy and splenopancreatectomy. We describe a 49-year-old woman who presented to our emergency department with acute moderate epigastric soreness and vomiting. She had undergone extensive gynecologic surgery including splenectomy 1 year before. The chest radiograph obtained in the emergency department demonstrated an elevated gastric air-fluid level in the left lower lung field. An urgent gastroscopy showed twisted structural abnormality of the stomach body. A computed tomography scan demonstrated the distended stomach, located in the left lower hemithorax through a left diaphragmatic defect. Emergent transthoracic repair was performed. Postoperative recovery was uneventful, and the patient did not experience any pain or difficulty with eating.
Gastric volvulus; Diaphragmatic hernia; Torsion; Emergency
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.
Malrotation with associated volvulus is a potentially lethal event for a neonate. The gold standard for diagnosis is an upper gastrointestinal contrast study. However this can delay the diagnosis and the timing of surgical intervention. We present a novel abdominal radiographic sign; duodenal and gastric dilatation occurring in association with limited small bowel gas confined to the right lower quadrant of abdomen and the total absence of colonic air that is indicative of malrotation with associated volvulus. This allows for an earlier diagnosis and expeditious surgery.
Malrotation; volvulus; abdominal radiograph
Gastric volvulus is a surgical emergency presenting in various forms. Association with diaphragmatic defect is well known. Here we describe three cases of gastric volvulus associated with diaphragmatic defect having varied presentations and their management. A rare case of gastric volvulus with complete gangrene of the stomach is also reported. Three types of gastric volvulus have been described depending on the rotation axis: organoaxial, mesentericoaxial and combination of both types. Operative treatment includes reduction, correction of underlying cause and gastropexy.
Volvulus; Gastropexy; Diaphragmatic hernia
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
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.
The authors describe a case of gastric volvulus, which is a rare cause of gastric outlet obstruction. An 85-year-old man presented with nausea, vomiting, and epigastric pain. Admission abdominal radiograph demonstrated a grossly distended stomach with air-fluid levels. Multiple attempts at nasogastric tube placement failed. Endoscopy revealed a fluid-filled, tortuous stomach with a paraesophageal hernia, and the operator was unable to locate or pass the scope through the pylorus. Traditionally Borchardt's triad is believed to be diagnostic for acute gastric volvulus and consists of unproductive retching, epigastric pain and distention, and the inability to pass a nasogastric tube. The authors propose that the following features on endoscopy are highly suggestive of the most common type of volvulus (organoaxial): tortuous stomach, paraesophageal hernia, and inability to locate or pass the scope through the pylorus.
Volvulus of the intestine is a surgical emergency. Volvulus of the small bowel is more common in children and is most often secondary to malrotation. Small bowel volvulus is an uncommon cause for small bowel obstruction in adults, and is more likely to be secondary to postoperative adhesive bands. Colonic volvulus is a rare cause of large bowel obstruction, but more common than small bowel volvulus. The sigmoid is most frequently involved, with redundant colon as the primary cause. Cecal volvulus most commonly is due to lack of fixation. Colonic volvulus has a specific radiographic appearance; however, small bowel volvulus is difficult to distinguish from other causes of small bowel obstruction by radiographic means. New surgical techniques with minimally invasive surgery are increasingly being applied to this old problem with good results in selected cases.
Volvulus; bowel obstruction; minimally invasive surgery
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
Intestinal malrotation occurs when there is a disruption in the normal embryological development of the bowel. The majority of patients present with clinical features in childhood, though rarely a first presentation can take place in adulthood. Recurrent bowel obstruction in patients with previous abdominal operation for midgut malrotation is mostly due to adhesions but very few reported cases have been due to recurrent volvulus. We present the case of a 22-year-old gentleman who had laparotomy in childhood for small bowel volvulus and then presented with acute bowel obstruction. Preoperative computerised tomography scan showed small bowel obstruction and features in keeping with midgut malrotation. Emergency laparotomy findings confirmed midgut malrotation with absent appendix, abnormal location of caecum, ascending colon and small bowel. In addition, there were small bowel volvulus and a segment of terminal ileal stricture. Limited right hemicolectomy was performed with excellent postoperative recovery. This case is presented to illustrate a rare occurrence and raise an awareness of the possibility of dreadful recurrent volvulus even several years following an initial Ladd’s procedure for midgut malrotation. Therefore, one will need to exercise a high index of suspicion and this becomes very crucial in order to ensure prompt surgical intervention and thereby preventing an attendant bowel ischaemia with its associated high fatality.
Gut volvulus; Intestinal malrotation; Acute bowel obstruction; Computerised tomography scan; Laparotomy
This report describes a case of septic peritonitis and gall bladder rupture in German shepherd dog that developed 7 d after surgical treatment for gastric dilation-volvulus. Histological examination confirmed gall bladder necrosis, secondary to an acute ischemic event. Postoperative acute necrotizing cholecystitis has not been a previously reported complication in dogs.
Duplication of the alimentary tract is an important surgical condition. It may occur anywhere in the gastrointestinal tract. An important complication of this entity is perforation of the normal or abnormal gut. Malrotation with midgut volvulus can be a surgical emergency. We present a patient, who presented as malrotation with midgut volvulus associated with perforated ileal duplication. The patient was successfully managed.
Alimentary tract duplication; malrotation; midgut volvulus; malrotation and duplication
Volvulus of sigmoid colon and cecum is not uncommon in tropical Africa, but gastric volvulus is relatively rare, especially when compared with various causes of peptic ulcer syndrome seen at the University College Hospital in Ibadan, Nigeria.
A case of chronic intermittent type of gastric volvulus with superficial gastric ulcerations was recently seen and treated by vagotomy, pyloroplasty, and gastropexy.
Predisposing factors, various types, presentations, and management of gastric volvulus are discussed.
Since an acute attack of gastric volvulus, which is rare and possibly fatal if not adequately treated, can be confused with gastric outlet obstruction resulting from chronic duodenal ulcer, which is common, an index of suspicion is essential for the diagnosis of gastric volvulus.
A radiological diagnosis of gastric volvulus (GV) was made in 11 of 576 consecutive upper gastrointestinal series at the University of Benin Teaching Hospital, Nigeria, over a two-year period. The clinical symptoms were thoracico-abdominal in three and abdominal in eight; these cases were evaluated as acute in three, acute upon chronic in two, and chronic in six. There was a significant delay in the diagnosis in all cases (except a neonate in the series), and no case was diagnosed on clinical grounds alone.
The predisposing factors (except the clinical misdiagnosis of the neonate) in six of the seven cases that came to surgery were: diaphragmatic hernia and perigastritis (left lung abscess, thoracic empyema), arteriomesenteric compression of the duodenum in pregnancy (peptic ulcer), splenomegaly (hepatosplenomegaly, ascites, esophageal varices), previous gastrojejunostomy (stomal ulcer, left subphrenic abscess) and two cases of intestinal malrotation with mesenteric abnormalities (small bowel obstruction in one and duodenal atresia in the other). In one idiopathic case, gastric outlet obstruction was clinically suspected prior to surgery. Thus, the putative rarity of GV in black Africans is not supported by this experience.
Gastric volvulus is a clinico-radiologic entity that may present with a confusing thoracico-abdominal symptom complex. A greater awareness of the radiologic features is quintessential to an expeditious and usually successful surgical management that will avoid potentially serious complications. Negative surgical findings do not exclude GV as the underlying cause of acute abdomens necessitating emergency laparotomies.
Surgical stapling equipment was used to create a gastropexy in 20 dogs undergoing
emergency surgery for gastric dilatation and volvulus (GDV). The technique
involved creation of a tunnel between the seromuscular layer and the submucosa
of the pyloric antrum, and a matching tunnel beneath the right m. transversus
abdominis. The arms of a gastrointestinal anastomosis stapling device were
introduced into the tunnels, and the device was fired to create the gastropexy.
One dog died of systemic sequelae of GDV during the early postoperative period.
None of the remaining 19 dogs developed a recurrence of GDV during follow-up
periods ranging from 5 to 43 months. In 11 dogs, the integrity of the gastropexy
was evaluated by abdominal ultrasonography and either negative contrast
gastrography or double contrast gastrography; in these dogs, the radiographic
and/or the ultrasonographic findings were suggestive of an intact gastropexy.
There were no complications involving the gastropexy staple line. The results of
this study indicate that an effective and consistent permanent gastropexy can be
created, using surgical stapling equipment.
Ingestion of multiple magnets in the pediatric population can cause risk for serious viscous injury.
Most foreign bodies that a child ingests pass harmlessly through the gastrointestinal tract. However, ingesting multiple magnets places a child at risk for serious viscus injury.
A 16-y-old boy swallowed multiple magnets and presented with abdominal pain and emesis. Upon laparoscopy, the boy was found to have malrotation with volvulus caused by a cecal magnet attracted to a gastric magnet, resulting in a gastrocecal fistula.
We review the management of magnet ingestion with an emphasis on a high index of suspicion and the use of laparoscopy for diagnosis, as well as the consequences of a coexisting rotational anomaly.
Magnets; Foreign bodies; Intestinal volvulus; Malrotation; Laparoscopy; Adolescent
A case of progressive extrahepatic biliary obstruction due to chronic midgut volvulus secondary to malrotation in a 5-month-old girl is presented. The obstruction to the bile duct was relieved after correction of the malrotation and division of the obstructing bands.
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.
The objective of this study was to determine if experimental gastric dilatation volvulus (GDV) would decrease adenosine triphosphate (ATP) concentration and increase membrane conductance of the canine gastric and jejunal mucosa. Male dogs (n = 15) weighing between 20 and 30 kg were used. Dogs were randomly assigned to 1 of 3 equal groups: Group 1 was control, group 2 was GDV, and group 3 was ischemia. All dogs were anesthetized for 210 min. Group 1 had no manipulation. Group 2 had GDV experimentally induced for 120 min followed by decompression, derotation, and reperfusion for 90 min. Group 3 had GDV experimentally induced for 210 min. Gastric (fundus and pylorus) and jejunal tissue was taken at 0, 120, and 210 min from all of the dogs. Tissue was analyzed for ATP concentration, mucosal conductance, and microscopic changes. The ATP concentration in the fundus did not change significantly from baseline in group 2, but decreased significantly below baseline at 210 min in group 3. The ATP concentration in the jejunum decreased significantly below baseline in groups 2 and 3 at 120 min, remaining significantly decreased in group 3 but returning to baseline at 210 min in group 2. Mucosal conductance of the fundus did not change significantly in any dog. Mucosal conductance of the jejunum increased at 120 min in groups 2 and 3, and became significantly increased above baseline at 210 min. The jejunal mucosa showed more profound cellular changes than the gastric mucosa. The jejunum showed substantial decreases in ATP concentration with an increase in mucosal conductance, suggesting cell membrane dysfunction. Dogs sustaining a GDV are likely to have a change in the activity of mucosal cells in the jejunum, which may be important in the pathophysiology of GDV.
Eventration of diaphragm associated with gastric volvulus is an uncommon condition.
We are reporting a case of a 60-year-old male having left sided total diaphragmatic eventration associated with chronic intermittent organo-axial gastric volvulus. The patient presented with progressive dyspnea and intermittent gastrointestinal symptoms. Plication of left hemidiaphragm with anterior gastropexy was performed through an abdominal approach. Postoperatively the patient's symptoms improved.
Symptomatic gastric volvulus associated with diaphragmatic eventration is a surgical emergency and always requires surgical repair.