CASE REPORTS IDIOPATHIC ORGANO-AXIAL VOLVULUS OF THE STOMACH: CASE REPORT *

Transcription

1 CASE REPORTS IDIOPATHIC ORGANO-AXIAL VOLVULUS OF THE STOMACH: CASE REPORT * By IRVING I. LASKY, M.D., and IRVING L. LICHTENSTEIN, M.D., Beverly Hills, California IN 1866 there appeared in the literature for the first time a report of recurrent gastric volvulus; Berti * described a forward, upward rotation of the stomach, traversing an arc of 180 degrees. Since that time an additional 100 cases have been documented. Gastric volvulus has been variously classified. Payer 2 divides this condition into two groups: idiopathic and secondary. Other authors utilize an anatomic framework of reference; the nature of the mesentery and character of rotation determine the nomenclature. Thus Borchardt 3 describes a supracolic and infracolic type, depending upon whether the colon assumes an anterior or posterior position in relationship to the body of the stomach. The etiology of gastric volvulus cannot be clearly defined. However, several factors are generally recognized as contributory. These may be classified as follows: I. Intrinsic A. Congenital 1. Abnormalities of the mesentery a. Failure of fixation of the greater omentum to the transverse colon b. Congenital elongation of the gastrocolic ligament 2. Eventration of the diaphragm 3. Hourglass stomach 4. Defects of the left lobe of the liver B. Acquired 1. Left diaphragmatic hernia 2. Tumors a. Gastric b. Perigastric 3. Displacement of adjacent organs 4. Inflammatory processes in the vicinity of the stomach * Received for publication January 30, Requests for reprints should be addressed to Irving I. Lasky, M.D., 450 North Bedford Drive, Beverly Hills, Calif. 126

2 Vol. 45, No. 1 CASE REPORTS 127 II. Extrinsic A. Somatic 1. Extra-abdominal pressure a. Girdles, trauma, et cetera 2. Gastric distention a. Food b. Aerophagy B. Psychic Whatever the contributory causes, it appears that the mechanism in the production of gastric volvulus is based on the relationship between the greater curvature of the stomach and the transverse colon, since the movements of these two structures are more or less coordinated by their loose attachment via the gastrocolic ligament. 4 As the greater curvature rotates upward, the transverse colon is pulled with it the greater the rotation, the more pronounced the ascent of the transverse colon. The transverse colon may finally rest above the level of the stomach, should the latter move 180 degrees around its axis. Conversely, if the transverse colon is forced into a supragastric position by virtue of aerocolon, congenital anomalies, et cetera, its displacement may conceivably initiate gastric volvulus. Regardless of the factors enumerated, in all cases reported some anatomic anomalies were present, especially the failure of fusion of the greater omentum with the transverse colon; this, naturally, renders the stomach susceptible to various displacements. The clinical picture of gastric volvulus varies. There may be a paucity or even complete absence of symptoms. Usually there is abdominal distress, which may be mild to severe, acute, intermittent or constant, depending on the degree of rotation. In those types in which acute upper abdominal distress occurs, Borchardt's triad may be helpful in the differential diagnosis. This syndrome consists of strong and generally fruitless efforts to vomit, circumscribed epigastric pain, and resistance to the passage of a stomach tube. 1 If emesis is productive, there is usually absence of bile, 6 presumably due to complete obstruction of the pars pylorica. To assist in establishing a diagnosis, some clinicians endeavor to pass a sound. However, because of the danger of perforation, 5 a barium swallow study is preferable. When rotation approaches 180 degrees, obstruction or strangulation of blood supply becomes imminent. Beyond axial rotation, patients usually present the clinical picture of an acute abdominal emergency, with signs of complete obstruction and progressive strangulation. Death may ensue unless relief is immediately afforded. Occasionally spontaneous reduction occurs. The treatment of gastric volvulus is surgical except in poor-risk patients and those with infrequent mild attacks easily controlled by brief intubation and supportive measures. CASE REPORT A 37 year old married Caucasian female who enjoyed prior good health was admitted to the Cedars of Lebanon Hospital on August 1, 1955, with a history of having suffered from recurrent upper gastric distress. In view of the contemplated treatment her past history was especially significant: early in 1953 she had suffered

3 128 IRVING I. LASKY AND IRVING L. LICHTENSTEIN July 1956 from an attack of acute abdominal pain for which an appendectomy was performed; reference to the records revealed that the appendix was normal. On October 10, 1955, the patient developed severe mid-upper gastric cramping pain two hours following the ingestion of a chicken dinner. The pain remained localized, returned in waves and was severe enough to cause her to writhe and double up. Shortly thereafter she vomited her recently ingested food; the vomitus was free of bile. One and a half hours later she developed shaking chills and became semistuporous. At this time examination revealed decided mid-upper abdominal tenderness; rebound tenderness was absent. The patient appeared markedly dehydrated and, although coherent and cooperative, was somewhat lethargic. Her blood pressure was 120/80 mm. of Hg and her pulse was 90 per minute. There were FIG. 1. Upper gastrointestinal series demonstrating volvulus.

4 Vol. 45, No. 1 CASE REPORTS 129 FIG. 2. Organo-axial volvulus. Stomach in normal position. Arrow indicates its direction of rotation. no other significant physical findings. Laboratory results were as follows: white blood count, 14,500, with 81% neutrophils (segmented, 72%, and stabs, 9%), 1% eosinophils, 15% lymphocytes, and 4% monocytes; red blood count, 4,950,000, with 89% hemoglobin (14.3 gm.) ; blood amylase, 110 units; carbon dioxide combining power, 14 vol.%; urinalysis: specific gravity of 1.035, 2 plus albumin, 4 plus glucose, FIG. 3. Artist's drawing of surgical repair. (From Lichtenstein and Lasky: Gastric volvulus, California Medicine; to be published.)

5 130 IRVING I. LASKY AND IRVING L. LICHTENSTEIN July 1956 FIG. 4. This film demonstrates the postoperative relationships of the stomach to the plicated colon. a trace of acetone, and a ph of 5.5; serology was negative; blood sugar was 181 mg.% during the evening of admission but fell to 99 mg.% the following morning, at which time the urine sugar was 1 plus and the acetone was negative. Curiously enough, several weeks later a glucose tolerance test was performed and found to be within normal limits. The sedimentation rate was 23 mm. per hour. The symptoms having largely subsided, the patient insisted on leaving the hospital, 48 hours following admission. The etiology of this condition was obscure, but some type of acute upper abdominal catastrophe was presumed. Following discharge the patient submitted to a series of x-rays. The cholecystography proved negative. The upper gastrointestinal films, however, revealed a gastric volvulus. When the patient was shifted from the P.A. to the lateral view with pedicle formation at the duodenum there was noted a complete shifting of the curvatures of the stomach (figure 1). The volvulus was easily reduced by returning

6 Vol. 45, No. 1 CASE REPORTS 131 the patient to a supine position. X-ray several months later confirmed these observations. Barium enema failed to demonstrate either intrinsic or extrinsic lesion of the colon, nor was there any evidence of general or anatomic variations; during fluoroscopy barium freely outlined the entire colon. Because of recurrent episodes of upper abdominal distress, and in view of the danger of obstruction and strangulation, the patient agreed to surgical correction of her gastric volvulus. Accordingly, on August 3, 1955, a laparotomy was performed which revealed undue mobility of the stomach and transverse colon, as well as a marked redundancy of the transverse mesocolon. A new plication method for correction of the volvulus was effected: the transverse portions of the hepatic and splenic flexures were affixed to the ascending and descending colon, respectively. This was supplemented by fixation of the greater curvature to the transverse colon (figure 3). Following surgery it was evident that the stomach was pulled and held down to the transverse colon and was no longer able to undergo torsion. The patient made an uneventful convalescence and gave immediate proof of the effectiveness of the operation: postural changes failed to reproduce the abdominal discomfort evident preoperatively. Follow-up serial x-rays taken on August 30, 1955, likewise demonstrated the efficacy of the procedure; although freely movable to palpation, the stomach did not demonstrate the marked increase in mobility apparent on previous examination, while films obtained in all planes, including an upright steep Trendelenburg, anterior-posterior, posterior-anterior and both oblique positions, denoted ideal fixation of the stomach (figure 4). SUMMARY AND CONCLUSIONS 1. A case of idiopathic gastric volvulus is added to the literature. 2. Acute gastric volvulus must be considered in the differential diagnosis of abdominal emergencies. In this regard one should keep in mind Borchardt's triad, viz., strong, vain efforts to vomit, circumscribed epigastric pain and resistance to passage of a stomach tube. 3. A new method of surgical correction is described; fixation of the stomach to the transverse colon and plication of the hepatic and splenic flexures serve to prevent volvulation of the stomach. SUMMARIO IN INTERLINGUA Cento casos de volvulo gastric se trova documentate in le litteratura depost que Berti primo describeva le condition in Le factores etiologic pote esser classificate sequentemente: I. Intrinsec A. Congenite 1. Anormalitates del mesenterio 2. Eventration del diaphragma 3. Stomacho bilocular 4. Defectos del lobo sinistre del hepate B. Acquirite 1. Hernia sinistro-diaphragmatic 2. Tumores 3. Displaciamento de organos vicin 4. Processos inflammatori in le vicinitate del stomacho II. Extrinsec A. Somatic 1. Pression extra-abdominal 2. Distension gastric B. Psvchic

7 132 IRVING I. LASKY AND IRVING L. LICHTENSTEIN July 1956 Proque le stomacho e le colon transverse es attachate al ligamento gastrocolic, le alteration del position de un de iste organos causa un rotation del altere. Le triade de Borchardt es utile in diagnoses differential. Su tres factores es (1) dolor epigastric, (2) van tentativas de vomito, e (3) resistentia al passage del tubo gastric. Quando medios medical non succede a reducer un volvulo, un urgente intervention chirurgic es possibilemente indicate pro prevenir strangulation. Es presentate le reporto de un caso illustrative de recurrente volvulo gastric. Esseva usate in iste caso un nove methodo chirurgic sin resection gastric. Le methodo consisteva in fixar le plus grande curvatura del stomacho al colon transverse post que le colon transverse esseva immobilisate per le plication del flexuras hepatic e splenic. Un post-operative evalutation clinic e roentgenologic demonstrava le efficacia del methodo. BIBLIOGRAPHY 1. Berti: Singolare attortigliamento dell'esofago col duodeno seguito da rapida morte, Gazz. med. ital. 9: 139, Payer, A.: Volvulus ventriculi und die Achsendrehung des Magens, Mitt, a d. Grenzgeb. d. Med. u. Chir. 20: , Borchardt, M.: Pathologie und Therapie des Magenvolvulus, Arch, f. klin. Chir. 74: 243, von Haberer, H.: Volvulus des Magens bei Carcinoma, Deutsche Ztschr. f. Chir. 115: 497, Toygar, O.: Die Formveranderungen des Magens (Kaskadenmagen, Volvulus des Magens), Schweiz. med. Wchnschr. 78: , Bockus, H.: Gastro-enterology, Vol. 1, The esophagus and the stomach, 1944, W. B. Saunders Co., Philadelphia, Pa.