Acute and chronic gastric volvulus in infants and children: who should be treated surgically?

Abstract

Gastric volvulus was first described by Berti in 1966. Whereas acute gastric volvulus is very rare, chronic gastric volvulus on the other hand is being diagnosed with increasing frequency. This is attributed to the liberal use of barium meal for the evaluation of infants and children with repeated attacks of vomiting and recurrent chest infection. This report describes our experience in the management of 36 infants and children with acute and chronic gastric volvulus. Their medical records were retrospectively reviewed for: age at diagnosis, sex, symptomatology, diagnosis, treatment and outcome. There were 22 males and 14 females. Their ages at presentation ranged from 1 week to 2.5 years (mean 6.7 months). Their symptomatology included repeated attacks of vomiting (30 patients), recurrent chest infection and asthma like symptoms (6 patients), failure to thrive (6 patients), chocking with feeds (3 patients), loose bowel motion (3 patients) and apnoea attack (1 patient). Two presented acutely with intrathoracic gastric volvulus. One of them had recurrent left diaphragmatic hernia while the other had a large paraesophageal hernia. The remaining patients had chronic intraabdominal gastric volvulus. Radiologically, all had organo-axial gastric volvulus except one who had mesenterico-axial gastric volvulus and 33 (97%) of them had demonstrable gastroesophageal reflux. Eleven were treated conservatively because their symptoms were mild to moderate and settled. The two patients with intrathoracic gastric volvulus underwent reduction of the contents, repair of the defect and anterior gastropexy. The remaining patients underwent gastropexy, both fundal and anterior. Intraoperatively, two were found to have diaphragmatic hernia, nine had mobile (non-fixed) spleen, and eight showed mobile stomach with lax ligaments. Post-operatively, all did well and showed good improvement with disappearance of their symptoms and increase in weight. Acute gastric volvulus is very rare. Prompt clinical suspicion and radiological assessment are essential to treat this life-threatening condition. Chronic gastric volvulus on the other hand is more common but under diagnosed. It should be included in the differential diagnosis of infants and children with repeated attacks of chest infection, vomiting and failure to thrive. Barium meal should form part of their investigations. The treatment of chronic gastric volvulus depends on their symptomatology. Those with mild to moderate symptoms should be treated conservatively, while those with persistent and severe symptoms should undergo anterior (to the abdominal wall) and fundal (to the diaphragm) gastropexy without fundoplication.

Congenital Paraesophageal Hernia with Intrathoracic Gastric Volvolus in Two Sisters

“…Gastric volvulus is an abnormal rotation of the stomach leading to partial or total obstruction, and according to the axis of rotation, it is classified into organoaxial, mesentericoaxial, and mixed [7–11]. In mesentericoaxial volvolus, the stomach rotates around an imaginary axis passing through the greater and lesser curvatures, while in organoaxial, the stomach rotates around an imaginary axis passing between the esophagogastric junction and the pylorus [7].…”

“…In mesentericoaxial volvolus, the stomach rotates around an imaginary axis passing through the greater and lesser curvatures, while in organoaxial, the stomach rotates around an imaginary axis passing between the esophagogastric junction and the pylorus [7]. Organo-axial volvolus is the commonest.…”

“…Gastric volvulus is rare in the pediatric age group, and depending on its presentation, it is also classified as acute where urgent surgical treatment is mandatory and chronic. Based on its location, gastric volvolus is classified into intra-abdominal and intrathoracic [7, 10]. Intrathoracic gastric volvolus is extremely rare and seen in children with diaphragmatic hernia, and intrathoracic herniation of the stomach.…”

Management dilemma in a paediatric patient with chronic gastric volvulus: a case report

“…While other studies have also highlighted the importance of a background including failure to thrive and recurrent chest infection 6. Furthermore, there is emerging evidence to suggest that gastric volvulus is associated with GORD,5 , 6 and a mobile spleen,6 an association that should not be surprising given the role of these structures in maintaining the normal position of the stomach. Our case report supports this emerging consensus.…”

“…While strangulation necessitates immediate surgical referral, less severe cases provide a greater degree of debate; some argue that chronic gastric volvulus should always be managed surgically in order to prevent an, as yet, unproven potential progression to acute volvulus; however, there does not appear to be a basis for this in the literature. A recent publication has suggested that treatment should be based upon the severity of symptoms such that those with mild symptoms should be treated conservatively and those with severe symptoms should be treated surgically 6. At present an evidence-based classification of symptoms into severe and mild has not been elucidated, if indeed such a classification exists.…”