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.
A YOUNG INFANT WITH PERSISTANT VOMITING AND FAILURE TO THRIVE<br />Dr.SaimaBashir<br /> Post Graduate Resident<br /> Department Of Paediatrics<br /> King Edward Medical University/Mayo Hospital, Lahore.<br />
Systemic review<br />No history of constipation, abdominal distension<br />No urinary complaint<br />
Treatment history<br />Treatment taken from local G.P and treated with oral medicines<br />Record not available<br />
Past history<br />He is having H/O vomiting from second day of life associated with feeding, multiple episodes<br />Relieved temporarily with medication from local G.P<br />Remained admitted once for similar complaint<br />
Abdominal usg andcolor Doppler<br />Normal pylorus<br />Color Doppler has shown superior mesenteric vein lying superior and lateral (right) to superior mesenteric artery indicating MALROTATION of gut<br />
Barium MEAL AND follow through<br />Suggestive of Gastric Volvulus (organoaxial)<br />
MANAGEMENT<br />Correction of dehydration and electrolyte imbalance<br />Antibiotic cover<br />Pediatric surgeon consultation<br />
DEFINITION <br />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.<br />Obstruction - acute, recurrent, intermittent, or chronic.<br />
FREQUENCY <br />Males and females are equally affected<br />Ten to 20% of cases occur in children,usually before age 1 year.<br />Cases have been reported in children up to age 15 years.<br />In children is often secondary to congenital diaphragmatic defects.<br />
Anatomy <br />The stomach is normally fixed to the abdominal cavity by 4 ligaments:<br /> 1. Gastrocolic<br /> 2. Gastrohepatic<br /> 3. Gastrophrenic<br /> 4. Gastrosplenic<br />
TYPES <br />Idiopathic or primary gastric volvulus (Type 1)<br />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.<br />Secondary gastric volvulus (Type 2) <br /> Congenital or acquired<br />1. Disorders of gastric anatomy or gastric<br /> Function<br />2. Abnormalities of adjacent organs<br />
ETIOLOGY <br />Primary volvulus: <br />Absence, failure of attachment, or elongation of gastric fixation<br />Secondary volvulus<br />Disorders of gastric anatomy or function<br />Acute or chronic distention (gastric outlet obstruction, hypomotility, or massive aerophagia)<br />Peptic ulcer disease<br />Neoplasm of the stomach<br />Hourglass stomach<br />Gastric ptosis<br />Abnormalities of adjacent organs<br />Diaphragm (hernia, rupture, eventration, phrenic nerve palsy)<br />Spleen (asplenia, polysplenia, splenomegaly, wandering spleen)<br />Transverse colon (volvulus, displacement into chest)<br />Intestinal malrotation<br />Liver (dislocation or hypoplasia of left lobe)<br />
Type 1<br />Comprises two thirds of cases<br />Presumably due to abnormal laxity of the gastrosplenic, gastroduodenal, gastrophrenic, and gastrohepatic ligaments. <br />More common in adults but has been reported in children<br />
Type 2<br />Found in one third of patients<br />Usually associated with congenital or acquired abnormalities that result in abnormal mobility of the stomach.<br />
CLINICAL FEATURES<br />The clinical presentation of gastric volvulus is nonspecific and suggests high intestinal obstruction. <br />Gastric volvulus presents as a triad of <br />A sudden onset of severe epigastric pain,<br />Intractable retching with emesis<br />Inability to pass a tube into the stomach.<br />
In infancy is usually associated with nonbilious vomiting.<br />May present as<br />Acute volvulus<br />Chronic volvulus<br />CLINICAL FEATURES<br />
DIAGNOSIS <br />Presence of a dilated stomach in plain abdominal radiograph. <br />Erect abdominal films demonstrate <br />In mesenteroaxial volvulus, a double fluid level with a characteristic “beak” near the lower esophageal junction. <br />In organoaxial volvulus, a single air-fluid level is seen without the characteristic beak.<br />
There have been 581 cases of gastric volvulus in children published in English between 1929 and 2007. <br />Of these, 252 were acute and 329 were chronic cases.<br />Of all children with acute volvulus, 54 (21%) presented in the first month of life.<br />Literature Review<br />
The majority of the patients presented with organoaxial volvulus (136 of 252 [54%]), while 103 (41%) cases of mesenteroaxial volvulus<br />Cribbs KR et al. Gastric Volvulus in Infants and Children. Pediatrics 2008;122:e752–e762.<br />Literature Review<br />
CONCLUSION<br />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.” <br />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.<br />