A young infant presented with persistent vomiting and failure to thrive. Imaging showed malrotation of the gut with the superior mesenteric vein lying superior and lateral to the superior mesenteric artery. Further imaging found gastric volvulus, which was corrected surgically. Gastric volvulus can be primary due to laxity of ligaments, or secondary to anatomical abnormalities, and presents as epigastric pain, vomiting, and inability to pass a tube into the stomach.

2. 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.

3. BIODATA

4. Presenting complaints

5. History of presenting illness

6. Systemic review No history of constipation, abdominal distension No urinary complaint

7. Treatment history Treatment taken from local G.P and treated with oral medicines Record not available

8. 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

9. MISCELANEOUS DETAILS

10. MISCELANEOUS DETAILS

11. examination A Malnourished Baby

12. GIT examination Soft, non tender abdomen No localized swelling or mass No visible peristalsis No visceromegaly Bowel sounds normal

13. others All Normal

14. Summing up evidences

15. Differential diagnosis Pyloric stenosis Malrotation of gut GERD RTA Adrenal insufficiency IEM

16. investigations

17. investigations

18. BSR: RFTs: LFTs: All Normal Urine C/E & C/S:

19. 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

20. Barium MEAL AND follow through Suggestive of Gastric Volvulus (organoaxial)

21. MANAGEMENT Correction of dehydration and electrolyte imbalance Antibiotic cover Pediatric surgeon consultation

22. Gastric Volvulus

23. 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.

24. 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.

25. Anatomy The stomach is normally fixed to the abdominal cavity by 4 ligaments: 1. Gastrocolic 2. Gastrohepatic 3. Gastrophrenic 4. Gastrosplenic

26. CLASSIFICATION Most commonly used classification system Organoaxial Mesentero-axial Combined

27. Organoaxial Volvulus

28. Mesentero-axial Volvulus

29. Combined Volvulus

30. 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

31. 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)

32. 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

33. Type 2 Found in one third of patients Usually associated with congenital or acquired abnormalities that result in abnormal mobility of the stomach.

34. 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.

35. In infancy is usually associated with nonbilious vomiting. May present as Acute volvulus Chronic volvulus CLINICAL FEATURES

36. 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.

37. TREATMENT Acute volvulus Surgical correction after stabilization Chronic volvulus Endoscopic correction

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

39. literature review

40. 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

41. 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

42. 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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