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Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
Gastric volvulus and other types of volvulus
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Gastric volvulus and other types of volvulus

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  • 1. Dr. Sudarshan Under Guidance of Dr. B. L. Yadav Assistant Professor, Upgraded Department of Surgery
  • 2. History Name: Bhori singh Age & sex: 45 yrs ,male Resident :Baroli ,Bharatpur DOA:05/01/2013 Clinical presentation Pain abdomen: last 3 days Abdominal distention: last 3 days Not passing flatus motion: last 2 days No h/o fever No h/o vomiting
  • 3. Cont.. Past history:  No h/o similar complaint  No h/o previous surgery  No h/o DM, TB, COPD, Hypertension , Bronchial Asthma Personal history  Smoker  Tobacco chewer  Non alcoholic  Normal bowel bladder habits
  • 4. Examination           Conscious Oriented Afebrile Pulse-92/min B.P-100/70 mmHg No pallor No L.N Pathy No icterus No clubbing No pedal oedema
  • 5. P/A Inspection:  Abdomen distended with fullness present in upper abdomen  No visible pulsation , peristalsis Palpation:  Abdomen is tense, tender  Guarding present  No Rigidity Percussion:  Tympanic note present  Normal liver dullness and span  No shifting dullness Auscultation:  Bowel sounds absent
  • 6. Investigations          HB- 11.6 gm/dl TLC- 1400 /mm3 PLT- 1.35 lakh/ml Serum urea/creatinine- 87/2.0 mg/dl S.Total bilirubin-1.2 mg/dl Direct- 0.5 mg/dl Indirect- 0.7 mg/dl SGOT/SGPT- 70/18 Serum amylase-175.0 u/lt Serum electrolytes- wnl X-Ray FPA- Multiple air fluid level with large single stomach gas shadow
  • 7. Provisional diagnosis:  Acute intestinal obstruction  Perforation peritonitis Plan:  Exploratory Laparotomy
  • 8. Procedure performed  Exploratory laparotomy with Gastropexy
  • 9. Per operative photos cranial R L caudal
  • 10. Cont… CRANIAL R L
  • 11. Cont.. cranial R L
  • 12. Cont.. Cranial Caudal
  • 13. Contd.. Stomach Fixed to Diaphragm & AnteroLateral Abdominal Wall With Silk
  • 14. Post operative follow up  Vitals monitoring  Input /output monitoring  Chest physiotherapy  Skin stitches removal-7th post op. day  Discharge-8th post op. day
  • 15. Discussion  Definition Gastric volvulus or volvulus of stomach a twisting of all or part of the Stomach by more than 180 degrees with obstruction of the flow of material through the stomach, variable loss of blood supply and possible tissue death.
  • 16. Cont..  Very uncommon clinical entity  First described by Berti in 1866  Seen in both children and elderly people  Rare below fifth decades of life
  • 17. Classification of gastric volvulus On the basis of: 1)OnsetAcute Chronic 2)Axis of rotation Organoaxial Mesentroaxial Combined
  • 18. Gastric volvulus 1. Organoaxial(along longitudinal axis-MC) a)Acute presentation b)associated with diaphragmatic defects c)more common in adults d)vascular compromise more common 2. Mesentroaxial (along vertical axis) a) recurrent episodes of pain abdomen b) Diaphragmatic defects are not seen c) more common in children 3. Combined
  • 19. Diagrammatic representation Organoaxial Mesentroaxial
  • 20. Aetiology  Type 1 or Idiopathic gastric volvulus comprises two thirds of cases and is presumably due to abnormal laxity of the gastrosplenic*, gastrocolic*, gastrophrenic and gastrohepatic* ligaments.
  • 21. Cont..  Type 2 or secondary Type 2 gastric volvulus is found in one third of patients and is usually associated with congenital or acquired abnormalities that result in abnormal mobility of the stomach  Diaphragmatic defect Eventration Paraoesophagial hiatal defect Trauma Paralysis  Congenital bands and adhesions  Intestinal malrotation  Pyloric stenosis and gastric distension  Colon distention
  • 22. AETIOLOGY
  • 23. Clinical features  Pain abdomen (acute in onset)  Recurrent retching with little vomitus  Inability to pass a Ryles tube OTHERS  Abdominal pain       Vomiting Upper GI bleed Dysphagia Gastro oesophageal reflux Respiratory symptoms Altered bowel habit Borchardts Triad
  • 24. Investigations  X Ray FPA- Gas filled viscus in chest and or upper     abdomen, multiple air fluid levels, Barium contrast studies :sensitive and specific Upper GI Endoscopy: both diagnostic and therapeutic USG CT scan abdomen and MRI
  • 25. X-ray findings in gastric volvulus
  • 26. Contd …
  • 27. Barium meal: Organoaxial volvulus Before surgery After surgery
  • 28. Mesentricoaxial Gastric volvulus
  • 29. Endoscopy view:
  • 30. USG:  Peanut sign in a case of chronic gastric volvulus.  The ultrasonographic features consist of a constricted segment of stomach, with 2 dilated segments located above and below the constricted part, akin to a peanut.  In several case reports, however, the ultrasonographic evaluation of gastric volvulus showed normal findings.
  • 31. CT image:
  • 32. Advantage of CT Scan  detection of gastric pneumatosis and pneumoperitoneum, suggestive of necrosis and perforation, respectively  detection of predisposing factors, e.g. diaphragmatic defects or hernias, dense adhesions  detection of other abnormalities associated with gastric volvulus, viz. wandering spleen, intrathoracic kidney, malrotation with asplenia  excluding other extra-gastric or vascular causes of gastric ischaemia
  • 33. Limitation of Techniques  Plain radiography may demonstrate findings that are indistinguishable from those that are produced by other causes of gastric atony or obstruction. However, the modality is useful for excluding other causes of the patient's symptoms, such as pneumoperitoneum or pneumothorax.  Barium study is highly sensitive and specific. However, the diagnosis may be missed in cases of intermittent torsion.
  • 34. Treatment  Aims: 1) Reduction of volvulus 2) Gastric fixation 3) Repair of predisposing factor  Apporach: Open Endoscopic Laproscopic Combined (endoscopic + laproscopic)
  • 35. Cont.. Open surgery:  Diaphragmatic hernia repair  Division of bands  Gastropexy  Partial gastrectomy(In case of necrosis)  Gastrojejunostomy  Repair of eventration of diaphragm
  • 36. Surgical procedures Anterior suture gastropexyThe stomach along the gastro colic omentum is suspended to the anterior abdominal wall Partial gastrectomy – Indicated if a portion of the stomach is gangrenous
  • 37. Cont.. Endoscopic : Reduction  Alpha loop maneuver  J type maneuver With or without gastrostomy(for fixation of stomach) (PEG)
  • 38. PEG Tube
  • 39. Cont.. Laproscopic  Reduction of volvulus  Anchoring fundus of stomach to diaphragm and greater curvature of stomach to anterior abdominal wall  Repair of diaphragmatic defects  fundoplication
  • 40. Cont.. Combined approach  Described by Arben Beqiri in 1997  Less time consuming  Endoscopic T-fasteners are used instead of PEG for anchoring stomach
  • 41. T-fastener system
  • 42. Method for providing apposition of two bodily walls a) forming a puncture site through the two walls; b) inserting an access cannula into the puncture site; c) passing a guide tube through the access cannula, the guide tube retroflexing after passing beyond a distal end of the access cannula; d) positioning a distal end of the guide tube proximate one of the bodily walls; e) passing a flexible puncturing device through the guide tube and puncturing the two bodily walls at a second location; f) connecting a fastener to the puncturing device; g) retracting the puncturing device to draw the fastener through the two bodily walls at the second location; and h) securing the fastener to maintain apposition of the two walls at the second location.
  • 43. Follow up     Clinical: Reflux symptoms Recurrence Removal of PEG Tube Imaging: Contrast study
  • 44. Complications of volvulus  Strangulation  Necrosis  Perforation of stomach  Gastrointestinal haemorrhage  Cardiopulmonary failure
  • 45. Complications related to PEG Tube  Wound infection  Peritonitis  Peristomal leakage  Dislodgement  Bowel perforation  Gastrocolic fistula
  • 46. Association  Wandering spleen  Congenital diaphragmatic hernia  Diaphragmatic eventration
  • 47. Chronic gastric volvulus  Patient presents with recurrent episodes of vague abdominal pain and discomfort  Bloating  Surgery is only indicated if the episodes of pain are severe and disabling  T/t of choice- conservative  Operation of choice-anterior gastropexy

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