Bogdan, an 18-month-old boy, comes in with an acute history of vomiting and abdominal distension. Upon assessment, he is found to be drowsy with a GCS of 9 and a severely distended abdomen. He is tachycardic with normal BP and saturations, however, he had prolonged CRT of 4 seconds peripherally and centrally.
You put out a resus call, put in an intraosseous line. Peripheral vascular access was challenging. After inserting an NG tube, over a litre of clear gastric content is aspirated.
What is gastric volvulus?
A gastric volvulus is a rare clinical entity. It is defined as an abnormal rotation of the stomach of more than 180°, which creates a closed-loop obstruction that can result in incarceration and strangulation. It can manifest either as an acute abdominal emergency or as a chronic intermittent problem.
The presenting symptoms depend on the degree of twisting and the rapidity of onset.
A systematic review of paediatric cases of acute gastric volvulus (Hung et al., 2019) explored its distinguishing features. It also outlined the diagnosis and management of this life-threatening condition.
Hung WY, Chin TW, Hsu YJ, Fu YW. Acute gastric volvulus in children: A systematic review. Formos J Surg 2019;52:161-8.
A total of 65 reported cases were reviewed, 37 cases were acute while the rest were thought to be chronic or intermittent. The age of the children varied from newborns to adolescents (0 to 15 years). The majority of children were in the preschool age range.
How does gastric volvulus present?
- Emesis in almost 65% of the cases, bilious, non-bilious, hematemesis and coffee ground vomiting.
- Abdominal pain and distention are is reported in 46% of the cases.
- Respiratory symptoms include respiratory distress, apnoea, and shortness of breath.
- Others – hypersalivation, non-productive retching and anorexia.
Less commonly reported symptoms were failure to thrive, chest pain, back pain and the inability to pass a nasogastric tube.
Congenital diaphragmatic hernias were associated with 40% of the cases, gastric ligament laxity in 10% and spleen abnormalities (wandering spleen and asplenia) in 9% of the cases.
How do we make the diagnosis?
An upper gastrointestinal contrast study is the most commonly used imaging modality in making the diagnosis of acute gastric volvulus. This is the gold standard.
Diagnosis is difficult and depends on radiology in children with suspicious clinical findings. Plain abdomen, chest ray, upper gastrointestinal series, and abdominal CT are also used in the diagnosis of gastric volvulus.
In a positive upper GI contrast, the stomach lies in the vertical plane, with the gastric antrum above the esophagogastric junction due to the mesenteric volvulus with gastric outlet obstruction.
What are the potential complications?
- Gastric ulceration
- Gastric perforation
- GI haemorrhage
- Pancreatic necrosis
- Omental avulsion
Malrotation of the stomach can even disrupt the splenic vessels, resulting in haemorrhage and splenic rupture.
How is gastric volvulus managed?
Aggressive fluid resuscitation and gastric decompression via NG are usually needed. Urgent referral to a tertiary surgical unit for emergency intervention is of paramount importance. In the 37 reviewed cases, 7 cases underwent laparoscopic surgery, 30 cases underwent laparotomy, and gastropexy was performed in 51.4%.
Bogdan needed extensive fluid resuscitation (60mls/kg of 0.9% saline) to restore his circulation. He was also given broad-spectrum antibiotics coverage for possible sepsis. An abdominal X-ray showed a severely distended stomach left-sided diaphragmatic hernia, and paucity of gas shadow in the distal abdomen, raising concern for acute obstruction.
The blood gas showed a raised lactate raising the concern for potential ischaemic bowels so he was referred to the tertiary paediatric surgical department and blue-lighted to the surgical unit. After a contrast study confirming the diagnosis, he underwent emergency surgery. Fortunately, there was no compromise to the gastric blood supply. He had a smooth post-operative course and made a complete recovery.
References
Pérez-Egido, Laura et al. “Acute gastric volvulus and congenital diaphragmatic hernia, case report and review.” African Journal of Paediatric Surgery: AJPS 12 (2015): 200 – 202.
Hung WY, Chin TW, Hsu YJ, Fu YW. Acute gastric volvulus in children: A systematic review. Formos J Surg 2019;52:161-8.
Upadhyaya VD, Gangopadhyay AN, Pandey A, Kumar V, Sharma SP, Gupta DK. Acute gastric volvulus in neonates – A diagnostic dilemma. Eur J Pediatr Surg 2008;18:18891.
