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.
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
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
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
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
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.
OUTCOME AND PROGNOSIS Acute volvulus Surgical correction after stabilization Chronic volvulus Endoscopic correction
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.