CASE CONFERENCE GASTRIC VOLVULUS PIKOM, MD NONGLUK, MD; RADIOLOGIST
IDENTIFICATION DATA ผ ป วยเด กชายไทย อาย 13 ว น เช อชาต ไทย ส ญชาต ไทย ภ ม ล าเนา จ งหว ด อ ท ยธาน เข าร บการร กษาท รพ.มหาว ทยาล ยนเรศวรว นท 18 พฤษภาคม พ.ศ. 2558 ประว ต ได จาก เวชระเบ ยน
PRESENT ILLNESS CASE TERM MALE NEWBORN 38+3 WEEKS, C/S DUE TO CPD (5/5/58) ม อาการอาเจ ยนเป นนม และน าเข ยวๆ หล งก นต งแต แรกคลอด ถ าย MACOMIUM 1-2 คร ง/ว น น าหน กลดลง 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 WANDERING SPLEEN TRAUMATIC INJURY TO DIAPHRAGM - ASPLENIA - PYLORIC STENOSIS - 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
Organoaxial volvulus - Rotation of the stomach along its long axis - GC = greater curvature - LC = lesser curvature Mesenteroaxial volvulus - Twisting along its short axis - A = gastric antrum - GEJ = gastroesophageal junction 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
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 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. 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 11 TH ED NEONATAL ACUTE GASTRIC VOLVULUS; IMAGES IN NEONATAL MEDICINE; ARCHIVES OF DISEASE IN CHILDHOOD - BMJ JOURNALS, 2003