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Gastric volvulus
 

Gastric volvulus

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  • Anion gap=11
  • Normal width and length of pylorus
  • A twisting or turning of the stomach of <180° that results in only partial foregut obstruction is best defined as “gastric torsion.”
  • Ligaments normally function to prevent twisting or turning about to anchor points:the gastroesophageal junction and pylorus
  • The most frequently used classification system of gastric volvulus, proposed by Singleton,[4 ] relates to the axis around which the stomach rotates
  • Longitudinal axis extend from gastroesophageal junction to the pylorusThe stomach may rotate on a longitudinAal axis that extends from the gastroesophageal junction to the pylorus.Rotation about this axis causes the greater curvature of the stomach to rest superior to the lesser curvature, resulting in an “upside-down” stomach. This is called “organoaxial volvulus”.
  • Mesenteroaxial axis extends from greater to lesser curvature of stomachCauses complete obstructionRotation of the stomach along an axis perpendicular to its longitudinal axis is called “mesentero-axial volvulus”
  • Rotation of the stomach about both the organoaxial and mesenteroaxial axes is termed “combined volvulus”.
  • Type 1:Comprises two thirds of cases. More common in adults but has been reported in childrenType 2:Found in one third of patients
  • This allows approximation of the cardia and pylorus when the stomach is full, predisposing to volvulus.
  • Acute volvulus: May advance rapidly to strangulation and perforation.Chronic gastric volvulus: More common in older childrenPresent with a history of Emesis, Abdominal pain, Early satiety.
  • Until 1980, 300 cases of gastric volvulus had been reported in the literature. Of these only 50 had presented in children. The disease is considered rare. Youssef SA, Di Lorenzo M, Yazbeck S, Ducharme JC. Gastric volvulus in children. Chir Pediatr. 1987;28(1):39–42Cribbs KR et al. Gastric Volvulus in Infants and Children. Pediatrics 2008;122:e752–e762.

Gastric volvulus Gastric volvulus Presentation Transcript

  • A YOUNG INFANT WITH PERSISTANT VOMITING AND FAILURE TO THRIVE
    Dr.SaimaBashir
    Post Graduate Resident
    Department Of Paediatrics
    King Edward Medical University/Mayo Hospital, Lahore.
  • BIODATA
  • Presenting complaints
  • History of presenting illness
  • Systemic review
    No history of constipation, abdominal distension
    No urinary complaint
  • Treatment history
    Treatment taken from local G.P and treated with oral medicines
    Record not available
  • Past history
    He is having H/O vomiting from second day of life associated with feeding, multiple episodes
    Relieved temporarily with medication from local G.P
    Remained admitted once for similar complaint
  • MISCELANEOUS DETAILS
  • MISCELANEOUS DETAILS
  • examination
    A Malnourished Baby
  • GIT examination
    Soft, non tender abdomen
    No localized swelling or mass
    No visible peristalsis
    No visceromegaly
    Bowel sounds normal
  • others
    All Normal
  • Summing up evidences
  • Differential diagnosis
    Pyloric stenosis
    Malrotation of gut
    GERD
    RTA
    Adrenal insufficiency
    IEM
  • investigations
  • investigations
  • BSR:
    RFTs:
    LFTs:
    All Normal
    Urine C/E & C/S:
  • Abdominal usg andcolor Doppler
    Normal pylorus
    Color Doppler has shown superior mesenteric vein lying superior and lateral (right) to superior mesenteric artery indicating MALROTATION of gut
  • Barium MEAL AND follow through
    Suggestive of Gastric Volvulus (organoaxial)
  • MANAGEMENT
    Correction of dehydration and electrolyte imbalance
    Antibiotic cover
    Pediatric surgeon consultation
  • Gastric Volvulus
  • DEFINITION
    Gastric volvulus” refers to the revolution of all or a portion of the stomach at least 180˚ about an axis that causes an obstruction of the foregut.
    Obstruction - acute, recurrent, intermittent, or chronic.
  • FREQUENCY
    Males and females are equally affected
    Ten to 20% of cases occur in children,usually before age 1 year.
    Cases have been reported in children up to age 15 years.
    In children is often secondary to congenital diaphragmatic defects.
  • Anatomy
    The stomach is normally fixed to the abdominal cavity by 4 ligaments:
    1. Gastrocolic
    2. Gastrohepatic
    3. Gastrophrenic
    4. Gastrosplenic
  • CLASSIFICATION
    Most commonly used classification system
    Organoaxial
    Mesentero-axial
    Combined
  • Organoaxial Volvulus
  • Mesentero-axial Volvulus
  • Combined Volvulus
  • TYPES
    Idiopathic or primary gastric volvulus (Type 1)
    Failure of these normal attachments may be the result of absence, elongation or disruption of the gastric ligaments, which results in idiopathic or primary gastric volvulus.
    Secondary gastric volvulus (Type 2)
    Congenital or acquired
    1. Disorders of gastric anatomy or gastric
    Function
    2. Abnormalities of adjacent organs
  • ETIOLOGY
    Primary volvulus:
    Absence, failure of attachment, or elongation of gastric fixation
    Secondary volvulus
    Disorders of gastric anatomy or function
    Acute or chronic distention (gastric outlet obstruction, hypomotility, or massive aerophagia)
    Peptic ulcer disease
    Neoplasm of the stomach
    Hourglass stomach
    Gastric ptosis
    Abnormalities of adjacent organs
    Diaphragm (hernia, rupture, eventration, phrenic nerve palsy)
    Spleen (asplenia, polysplenia, splenomegaly, wandering spleen)
    Transverse colon (volvulus, displacement into chest)
    Intestinal malrotation
    Liver (dislocation or hypoplasia of left lobe)
  • Type 1
    Comprises two thirds of cases
    Presumably due to abnormal laxity of the gastrosplenic, gastroduodenal, gastrophrenic, and gastrohepatic ligaments.
    More common in adults but has been reported in children
  • Type 2
    Found in one third of patients
    Usually associated with congenital or acquired abnormalities that result in abnormal mobility of the stomach.
  • CLINICAL FEATURES
    The clinical presentation of gastric volvulus is nonspecific and suggests high intestinal obstruction.
    Gastric volvulus presents as a triad of
    A sudden onset of severe epigastric pain,
    Intractable retching with emesis
    Inability to pass a tube into the stomach.
  • In infancy is usually associated with nonbilious vomiting.
    May present as
    Acute volvulus
    Chronic volvulus
    CLINICAL FEATURES
  • DIAGNOSIS
    Presence of a dilated stomach in plain abdominal radiograph.
    Erect abdominal films demonstrate
    In mesenteroaxial volvulus, a double fluid level with a characteristic “beak” near the lower esophageal junction.
    In organoaxial volvulus, a single air-fluid level is seen without the characteristic beak.
  • TREATMENT
    Acute volvulus
    Surgical correction after stabilization
    Chronic volvulus
    Endoscopic correction
  • OUTCOME AND PROGNOSIS
    Acute volvulus
    Surgical correction after stabilization
    Chronic volvulus
    Endoscopic correction
  • literature review
  • There have been 581 cases of gastric volvulus in children published in English between 1929 and 2007.
    Of these, 252 were acute and 329 were chronic cases.
    Of all children with acute volvulus, 54 (21%) presented in the first month of life.
    Literature Review
  • The majority of the patients presented with organoaxial volvulus (136 of 252 [54%]), while 103 (41%) cases of mesenteroaxial volvulus
    Cribbs KR et al. Gastric Volvulus in Infants and Children. Pediatrics 2008;122:e752–e762.
    Literature Review
  • CONCLUSION
    Gastric volvulus is not the rare condition it was once thought to be; as Youssef et al stated more than 20 years ago, “perhaps this entity is more common than generally thought.”
    It does require a heightened sense of awareness by pediatric providers to avoid delays in appropriate therapy and minimize the risk of gastric ischemia and perforation, which can lead to death.
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