CASE CONFERENCEGASTRIC VOLVULUS

PIKOM, MD

NONGLUK, MD; RADIOLOGIST

IDENTIFICATION DATA

• ผู้ ป่วยเดก็ชายไทย อาย ุ13 วนั

• เชือ้ชาติไทย สญัชาติไทย

• ภมิูลําเนา จงัหวดั อทุยัธานี

• เข้ารับการรักษาท่ี รพ.มหาวิทยาลยันเรศวรวนัท่ี 18 พฤษภาคม พ.ศ. 2558

• ประวตัิได้จาก เวชระเบียน

PRESENT ILLNESS

• CASE TERM MALE NEWBORN 38+3 WEEKS, C/S DUE TO CPD (5/5/58)

• มีอาการอาเจียนเป็นนม และนํา้เขียวๆ หลงักินตัง้แตแ่รกคลอด ถ่าย MACOMIUM1-2 ครัง้/วนั นํา้หนกัลดลง

• PHYSICAL EXAMINATION

• ABDOMEN: SCAPHOID ABDOMEN, SOFT, NO MASS

INVESTIGATION

• FILM CHEST X-RAY INCLUDE ABDOMEN (8/5/58)• DILATED STOMACH, NOT SEEN AIR IN BOWEL AND RECTUM

• ULTRASOUND ABDOMEN (12/5/58)• NO EVIDENCE OF HYPERTROPHIC PYLORIC STENOSIS

MANAGEMENT

• NPO

• OG TUBE

• ON TPN

• SENT FOR UPPER GI STUDY

UPPER GI STUDY

-> Left diaphragmatic elevation (red arrow) -> Air- contrast filled dilated stomach-> Air in bowel loops distal to stomach is seen.

UPPER GI STUDY

- Antrum (green arrow) superior and higher than gastroesophageal junction (red arrow)- The contrast media cannot pass to duodenum

DIAGNOSIS

• MESENTERO-AXIAL GASTRIC VOLVULUS WITH PARTIAL GUT OBSTRUCTION

GASTRIC VOLVULUS

• ROTATION OF THE STOMACH OF MORE THAN 180° AROUND THE AXIS

• CAUSES OBSTRUCTION OF THE GASTROINTESTINAL TRACT

• ROTATION OF THE STOMACH OF <180° THAT LEADS TO ONLY PARTIAL FOREGUT OBSTRUCTION IS DEFINED AS ‘GASTRIC TORSION’

• GENERALLY CONSIDERED RARE IN THE PEDIATRIC POPULATION

• DEFINITIVE DIAGNOSIS IS MADE WITH UPPER RADIOLOGICAL GASTROINTESTINAL STUDIES

PATHOPHYSIOLOGY

• STOMACH FIXES BY FOUR LIGAMENTS

• ABNORMAL -> CAN ROTATE ALONG AN AXIS PERPENDICULAR TO ITS LONG AXIS

• ASSOCIATED WITH ELEVATION OF THE LEFT HEMIDIAPHRAGM

• MAY BE OBSTRUCTION OF BOTH THE GASTRIC INLET AND GASTRIC OUTLET

ANATOMY

From: https://classconnection.s3.amazonaws.com/119/flashcards/690119/jpg/stomach_diagram1318786515876.jpg

ANATOMY

ETIOLOGICAL OF GASTRIC VOLVULUS

• PRIMARY GV

• ABSENCE OR LAXITY OF LIGAMENTS ATTACHING THE STOMACH TO THE SURROUNDING STRUCTURES

• SECONDARY GV (ANATOMIC DEFECTS)

• ELEVATION AND DIAPHRAGMATIC HERNIA

• MALROTATION OF GUT - ASPLENIA

• WANDERING SPLEEN - PYLORIC STENOSIS

• TRAUMATIC INJURY TO DIAPHRAGM - PHRENIC NERVE PALSY

ETIOLOGICAL OF GASTRIC VOLVULUS

From: Pediatric Gastric Volvulus: Diagnostic and Clinical Approach; Case Report in Gastroenterology 2013;7:63–68

PRESENTATION

• CHRONIC VOMITING, ABDOMINAL DISTENSION, FAILURE TO THRIVE AND RECURRENT CHEST INFECTION

• THE BORCHARDT TRIAD

• SUDDEN EPIGASTRIUM PAIN

• INTRACTABLE RETCHING

• INABILITY TO PASS A NASOGASTRIC TUBE INTO THE STOMACH

PRESENTATION

From: Pediatric Gastric Volvulus: Diagnostic and Clinical Approach; Case Report in Gastroenterology 2013;7:63–68

PHYSICAL EXAMINATION

• NONSPECIFIC

• EPIGASTRIC TENDERNESS AND DISTENTION

• PERITONITIS IN CASES OF STOMACH NECROSIS OR SEVERE OBSTRUCTION

TYPES OF GASTRIC VOLVULUS

• ORGANOAXIAL VOLVULUS

• ROTATE AROUND ITS LONG AXIS

• MORE COMMON THAN MESENTEROAXIAL VOLVULUS

• ASSOCIATION WITH LARGE HIATAL HERNIAS (PARTICULARLY OF THE PARAESOPHAGEAL TYPE)

• MESENTEROAXIAL TYPE

• TRUE EMERGENCY -> TWIST CAN COMPROMISE THE BLOOD SUPPLY TO THE STOMACH

TWO TYPES GASTRIC VOLVULUS

A -> Gastric ligamentous fixation - Gastrohepatic - Gastrophrenic - Gastrocolic - Gastrosplenic

B -> Rotation of the stomach - Short axis: mesenteroaxial volvulus- Long axis: organoaxial volvulus

From: Gastric volvulus; Caffey Pediatric imaging 11th

Mesenteroaxial volvulus- Twisting along its short axis - A = gastric antrum- GEJ = gastroesophagealjunction

Organoaxial volvulus - Rotation of the stomach along its long axis- GC = greater curvature - LC = lesser curvature

From: Volvulus of the Gastrointestinal Tract: Appearances at Multimodality Imaging; radiographics, 2009

• LINE A–A -> ORGANOAXIAL VOLVULUS

• LINE B–B -> MESENTEROAXIAL VOLVULUS

From: Gastric volvulus; Caffey Pediatric imaging 11th

RADIOGRAPHS

• PLAIN RADIOGRAPHS OF THE CHEST AND ABDOMEN

• LARGE DISTENDED STOMACH BELOW AN ELEVATED LEFT HEMIDIAPHRAGM

• UPPER GASTROINTESTINAL CONTRAST STUDY

• HELP TO DIAGNOSTIC

• DETERMINED THE TYPE OF VOLVULUS

• CT WAS NOT NECESSARY IN EITHER CHILD AND IT DELAYED SURGERY

Plain radiograph of chest and abdomen -> Left diaphragmatic elevation -> Gastric air shadow in left chest-> Dilated oesophagus-> Gasless abdomen

Upper gastrointestinal contrast study lateral view -> Left diaphragmatic elevation and organoaxial gastric volvulus: - Upside down stomach with reversal of

greater and lesser curvatures- Greater curvature (white arrows) crossing

the esophagus - Gastric outlet obstruction.

From: Neonatal acute gastric volvulus; IMAGES IN NEONATAL MEDICINE; Archives of Disease in Childhood - BMJ Journals, 2003

• MESENTEROAXIAL VOLVULUS IN A 7-YEAR-OLD GIRL WITH ABDOMINAL PAIN AND DISTENTION

• AT SURGERY, THE VOLVULUS WAS EASILY REDUCED, AND THE DIAPHRAGMATIC ELEVATION WAS REPAIRED.

A -> Lateral chest radiograph - Elevation of the left diaphragm (arrow)

B -> Frontal radiograph: upper GI series - Gastroesophageal junction: normal to slightly low in position - Pylorus superior and higher than gastroesophageal junction

From: Gastric volvulus; Caffey Pediatric imaging 11th

TREATMENT

• ACUTE GV OFTEN REQUIRES IMMEDIATE SURGICAL TREATMENT

• CHRONIC GV SHOULD BE TREATED CONSERVATIVELY

• PRONE POSITION WITH HEAD SLIGHTLY UP

• PROKINETICS

• ANTISECRETORY DRUGS

SURGICAL INTERVENTION

• DIAPHRAGMATIC HERNIA REPAIR

• SIMPLE GASTROPEXY

• GASTROPEXY WITH DIVISION OF THE GASTROCOLIC OMENTUM

• PARTIAL GASTRECTOMY

• FUNDOANTRAL GASTROGASTROSTOMY (OPOLZER'S OPERATION)

• REPAIR OF EVENTRATION OF THE DIAPHRAGM

TAKE HOME MESSAGES

• ROTATION OF THE STOMACH >180° GASTRIC VOLVULUS; <180°‘GASTRIC TORSION’

• ETIOLOGY: PRIMARY (ABSENT OR LAXITY OF LIGAMENT), SECONDARY (ANATOMICAL DEFECT)

• BORCHARHT TRIAD: SUDDEN EPIGASTRIUM PAIN, INTRACTABLE RETCHING, AND CANNOT PASS NG TUBE

• RADIOLOGY: UPPER GI CONTRAST STUDY TO DIAGNOSIS WITH DETERMINED TYPE (ORGANOAXIAL VS. MESENTEROAXIAL)

• TREATMENT: SURGERY VS. CONSERVATIVE

REFERENCES

• FEDERICA PORCARO; PEDIATRIC GASTRIC VOLVULUS: DIAGNOSTIC AND CLINICAL APPROACH; CASE REPORT IN GASTROENTEROLOGY 2013;7:63–68

• CAFFEY PEDIATRIC IMAGING 11TH ED

• NEONATAL ACUTE GASTRIC VOLVULUS; IMAGES IN NEONATAL MEDICINE; ARCHIVES OF DISEASE IN CHILDHOOD - BMJ JOURNALS, 2003