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ABSTRACT
Acute gastric volvulus secondary to
malrotation of gut is a rare surgical emergency. We report a case of an eight
years old cerebral palsy (CP) child who presented to us with sudden upper
abdominal distension and non productive retching. X-ray abdomen revealed a huge
gas shadow on left side of abdomen with paucity of distal gas shadows. On
exploration organoaxial gastric volvulus with gastric ischemia, secondary to
malrotation of gut, was found. Volvulus derotated and Ladd’s procedure was done.
Gastropexy and fundoplication was not done due to gastric ischemia. Early
diagnosis and surgical management can save the patient from fatal complications
of gastric perforation due to gastric ischemia.
KEY
WORDS Acute gastric volvulus, Gastric
ischemia, Malrotation, Gastropexy
HOW TO CITE
Kayastha K, Sheikh A. Acute gastric volvulus secondary to
malrotation of gut in a child with cerebral palsy. APSP J Case Rep 2011;
2:12.
INTRODUCTION
Gastric volvulus is an abnormal
rotation of stomach, more than 180 degree, on its own axis. The predisposing
factors of gastric volvulus are either abnormal laxity of various ligaments
around stomach or other anatomical causes. Malrotation of gut is an extremely
rare cause of secondary gastric volvulus in which partial duodenal obstruction
leads to the distension of stomach followed by twisting. Gastric ischemia may
occur due to strangulation of stomach [1-3].
We report a patient of cerebral
palsy with acute gastric volvulus and ischemia secondary to the malrotation of
gut.
CASE REPORT
An eight years old girl with cerebral palsy presented with 4-day
history of abdominal distension and retching. On examination there was marked
distension of left side of epigastrium. Superficial palpation revealed slight
tenderness over the distended area. The child was in obvious discomfort. Her
vitals were - temp 101 °F, BP 110/70, pulse 120/min, respiratory rate 30/min.
She was mildly dehydrated. Intravenous fluids and antibiotics were started.
Nasogastric tube was passed but it could not decompress the distension. Baseline
investigations were done; blood picture revealed leukocytosis. X-ray abdomen was
performed which showed a huge air fluid level on left side with paucity of
distal gas shadows (Fig. 1).
On the basis of the history, clinical
examinations and x-ray abdomen, a provisional diagnosis of acute gastric
volvulus was made. A decision for immediate exploration was taken. Blood was
arranged and written consent was taken from parents for surgical exploration.
Through supraumbilical transverse laparotomy incision a hugely distended stomach
with greater curvature lying superiorly, was identified. The stomach was gently
pulled out and derotated thus placing the greater curvature down to its original
position. As soon as the stomach was placed in normal position the nasogastric
aspirate increased and stomach got decompressed. There were ischemic patches
over the anterior surface of stomach and the fundus which were left as such
(Fig. 2,3). On further exploration of abdomen malrotation was found with
duodeno-jejunal junction ( DJ) on right of midline, mobile cecum and presence of
Ladd’s band. The Ladd’s procedure was done to correct the malrotation. There was
no diaphragmatic defect and spleen was placed in its normal position. Due to
ischemia of the stomach fundoplication and gastropexy were not
attempted.
The post-operative course remained uneventful and patient
discharged on 8th day. In follow up she remained well and was
referred to developmental OPD for management of cerebral
palsy.
DISCUSSION
Gastric volvulus is a rare surgical emergency. According to the
axis of rotation gastric volvulus can be organoaxial, mesentericoaxial or
combined. In case of organoaxial volvulus the stomach rotates around the axis
made by joining eosophagogastric junction and the pylorus. The greater curvature
either lies anteriorly or superiorly, as found in our case [1].
The
gastric volvulus can be primary which is the result of either absence or laxity
of various ligaments attaching the stomach to the surrounding structures. The
secondary gastric volvulus can occur due to various anatomic defects like
diaphragmatic hernia, malrotation of gut, asplenia, wandering spleen, pyloric
stenosis, traumatic injury to diaphragm, phrenic nerve palsy, abdominal tumors
etc [3-7]. In our case, acute gastric volvulus was secondary to malrotation of
gut. We hypothesize that partial duodenal obstruction might result in gastric
over-distension that predispose to an abnormal rotation of stomach around its
long axis.
The gastric volvulus may present as acute surgical emergency
or with chronic intermittent symptoms. In acute gastric volvulus there is sudden
upper abdominal distension associated with pain abdomen. Patient may present
with retching as well. In adults the classical Borchardt’s triad may be found
which include sudden pain in abdomen, non productive retching and inability to
pass NG tube. In case of chronic gastric volvulus the abdominal pain and
distension is intermittent as the stomach derotates itself at times. Early
satiety and fullness after meal may be the symptoms [1,3,5].
Both plain
and contrast radiographs of abdomen play vital role in diagnosis of gastric
volvulus. Plain x-ray abdomen shows typical large air fluid level at the left
upper quadrant with paucity of distal gas shadows in organoaxial rotation;
similar was found in our case. The barium study is more specific as it can show
the position of greater curvature, pylorus and the antrum if done with stomach
in twisted state [3].
Acute gastric volvulus is a surgical
emergency. The delay in the diagnosis and management may result in serious
complications like gastric necrosis, gastric perforation, sepsis and
cardiovascular failure [6]. In our case the gastric ischemia had occurred
however the stomach was viable after derotation.
The surgical management
of gastric volvulus is based upon three principles namely decompression of the
distended stomach, correction of volvulus and prevention of recurrence. Both
open as well as laparoscopic approaches have been advocated. Stomach should be
inspected for any ischemia or necrosis due to the strangulation. If any doubt in
viability of stomach arises, then segmental, subtotal or total gastrectomy can
be done. Anterior gastropexy, gastrostomy or fundoplication may be added for
prevention of gastric volvulus. However correction of various anatomical defects
in case of secondary gastric volvulus should always be kept in mind [1-5]. Our
patient was managed without any additional procedure on stomach as it was
secondary to malrotation.
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IMAGES
CASE REPORT
APSP J Case Rep 2011; Vol. 2 (2)
OPEN
ACCESS
Acute Gastric Volvulus Secondary to
Malrotation of Gut in a Child with Cerebral Palsy
Kanchan Kayastha,* Afzal
Sheikh
Department
of Pediatric Surgery, The Children's Hospital and the Institute of Child
Health Lahore, Pakistan
*Corresponding Author's E-mail address:
drkanchan1@hotmail.com
APSP J Case Rep
2011; 2: 12
Received on: 15-06-2011
Accepted on: 23-06-2011
http://www.apspjcaserep.com
This work is licensed
under a Creative
Commons Attribution 3.0 Unported License
Competing Interests:
None declared
Source of Support: Nil