High risk and low incidence diseases: Pediatric digestive volvulus.

INTRODUCTION: Pediatric digestive volvulus is a serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE: This review highlights the pearls and pitfalls of pediatric digestive volvulus, including the presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION: Pediatric digestive volvulus is a deadly condition most commonly associated with malrotation. It occurs when the stomach or small intestine twists on itself, resulting in ischemia and potentially strangulation with necrosis and perforation. Presentation differs based on the gastrointestinal (GI) segment affected, degree of twisting, and acuity of the volvulus. Gastric volvulus most commonly presents with retching with or without nonbilious emesis and epigastric distension with pain, while midgut volvulus typically presents with bilious emesis in infants. Patients with GI necrosis and perforation may present with hemodynamic compromise and peritonitis. If suspected, emergent consultation with the pediatric surgery specialist is necessary, and if this is not available, transfer to a center with a pediatric surgeon is recommended. Imaging includes plain radiography, ultrasound, or upper GI series, while treatment includes resuscitation, administration of antibiotics, and emergent surgical decompression and detorsion of the involved segments. CONCLUSION: An understanding of pediatric digestive volvulus and its many potential mimics can assist emergency clinicians in diagnosing and managing this deadly disease.

An acute gastric volvulus in a child with congenital left diaphragmatic hernia: a case report.

BACKGROUND: Acute complete gastric volvulus is a rare and life-threatening disease, which is prone to gastric wall ischemia, perforation, and necrosis. If it is not treated by surgery in time, the mortality rate can range from 30 to 50%. Clinical presentations of acute gastric volvulus are atypical and often mimic other abdominal conditions such as gastritis, gastroesophageal reflux, gastric dilation, and pancreatitis. Imaging studies are crucial for diagnosis, with barium meal fluoroscopy being the primary modality for diagnosing gastric volvulus. Cases of acute gastric volvulus diagnosed by ultrasound are rarely reported. CASE PRESENTATION: We reported a rare case of acute gastric volvulus in a 4-year-old Chinese girl who presented with vomiting and abdominal pain. Ultrasound examination revealed the "whirlpool sign" in the cardia region, raising suspicion of gastric volvulus. Diagnosis was confirmed by X-ray barium meal fluoroscopy, which indicated left-sided diaphragmatic hernia and obstruction at the cardia region. Surgical intervention confirmed our suspicion of acute complete gastric volvulus combined with diaphragmatic hernia. CONCLUSION: In this case, we reported an instance of acute complete gastric volvulus. Ultrasound revealed a "whirlpool sign" in the cardia, which is likely to be a key sign for the diagnosis of complete gastric volvulus.

Comprehensive Review: Acute Esophageal Necrosis in the Setting of Gastric Volvulus.

BACKGROUND AND AIMS: Acute esophageal necrosis (AEN) in the setting of gastric volvulus is a rare condition with only a handful of cases reported. Volvulus may contribute to AEN by limiting tissue perfusion and promoting massive reflux of gastric contents on compromised esophageal mucosa. METHODS: We reviewed 225 original articles, literature reviews, case series, brief reports, case reports, and discuss six total cases of co-occurring esophageal necrosis and gastric volvulus. RESULTS AND CONCLUSIONS: We present the first comprehensive analysis of all reported cases in the literature to date and formulate management strategies for the co-occurrence of AEN and volvulus. Management of AEN should be directed at correcting underlying medical conditions, providing hemodynamic support, initiating nil-per-os restriction, and administering high-dose proton pump inhibitor therapy. Surgical intervention is typically reserved for cases of esophageal perforation with mediastinitis and abscess formation.

Patients with gastric volvulus recurrence have high incidence of wandering spleen requiring laparoscopic gastropexy and splenopexy.

PURPOSE: Though gastric volvulus in neonates and infants resolves by conservative therapy and aging, some cases require surgical intervention. This study aimed to review the cases of gastric volvulus requiring surgical intervention and evaluate their characteristics. METHODS: We retrospectively reviewed gastric volvulus cases requiring surgical intervention. Surgical indication was persistent acute gastric volvulus and repeated hospitalization for gastric volvulus. We evaluated the characteristics of those cases requiring surgical intervention and the surgical results of laparoscopic gastropexy. RESULTS: The median age of patients included was 4 years (range: 1-6 years). All eight cases of gastric volvulus requiring sugery had congenital spleen diseases. Six of the eight cases suffered from a wandering spleen, while two cases presented with situs inversus with asplenia. Both splenopexy (preperitoneal distension balloon [PDB] or blunt separaion methods) and gastropexy were performed in cases with wandering spleen. No postoperative complications were reported in any of the eight cases, except the recurrence of gastric volvulus due to suture shedding in one case. CONCLUSION: Laparoscopic gastropexy for gastric volvulus and splenopexy for cases concomitant with wandering spleen were found to be effective surgical approaches. Both PDB and blunt separation methods for making extraperitoneal pockets for the spleen were employed successfully.

Gastric obstruction secondary to abdominal re-herniation of a giant hiatal hernia. An illustrative case to understand the pathophysiology of gastric volvulus.

Purpose: To depict the characteristics of a special type of gastric volvulus caused by acute re-herniation of a previous hiatal hernia.Materials and methods: We present the case of a male patient with known history of a giant hiatal hernia who presented to our emergency department with a chief complaint of epigastric pain, oral intolerance and incoercible vomiting in the last 24 h. On suspicion of abdominal complication, an emergent computed tomography (CT) scan was performed.Results: Gastric volvulus secondary to downward re-herniation of the fundus into the abdominal cavity was the cause of this patient's symptoms. This mechanism, which was demonstrated by comparing the CT findings of the acute episode with previous imaging studies, reveals a largely unrecognized pathogenic mechanism of gastric volvulus.Conclusions: Acute gastric volvulus should be suspected in patients with hiatal hernia. CT allows its diagnosis and likely underlying pathophysiological mechanism.

Counterclockwise gastric dilatation and volvulus in a dog.

A 6-year-old neutered male golden retriever mix dog was presented for investigation of acute restlessness, increased respiratory effort, non-productive retching, and anorexia. Initial abdominal radiography revealed marked gastric dilation with a normal gastric shape and position, along with mineralized granular material in the pyloric region, consistent with a pyloric outflow obstruction secondary to suspected sand impaction. The dog was stabilized with gastric trocharization and medical management with intravenous fluids, antiemetics, polyethylene glycol via a nasogastric tube, and analgesia was initiated. The dog developed aspiration pneumonia during hospitalization and became oxygen-dependent. There was no significant improvement of clinical status despite 72 h of medical management, and surgical intervention was subsequently recommended. Exploratory laparotomy revealed a counterclockwise gastric dilatation and volvulus. The stomach was repositioned into normal anatomic position and an incisional gastropexy was performed. The dog was maintained in the intensive care unit for 4 d postoperatively. Currently, 3 mo postoperatively, the dog is healthy without recurrence of clinical signs. Key clinical message: Counterclockwise gastric dilatation and volvulus is a rare condition in veterinary medicine; however, it should be considered in a patient with acute gastric distension and signs of pyloric outflow obstruction when characteristic radiological signs of clockwise gastric dilatation and volvulus are absent, and there is radiological evidence of persistent gastric foreign material despite medical management. Misdiagnosis of counterclockwise gastric dilatation and volvulus can delay definitive surgical intervention and lead to higher morbidity and mortality.

Dilatation gastrique dans le sens inverse des aiguilles d'une montre et volvulus chez un chien. Un chien golden retriever mâle castré âgé de 6 ans a été présenté pour évaluation à la suite d'agitation aiguë, d'un effort respiratoire accru, des haut-le-coeur non productifs et d'anorexie. La radiographie abdominale initiale a révélé une dilatation gastrique marquée avec une forme et une position gastrique normales, ainsi qu'un matériau granulaire minéralisé dans la région pylorique, compatible avec une suspicion d'obstruction de l'écoulement pylorique secondaire à une impaction par du sable. Le chien a été stabilisé avec une trocarisation gastrique et une prise en charge médicale avec des fluides intraveineux, des antiémétiques, du polyéthylène glycol via une sonde nasogastrique, et une analgésie a été initiée. Le chien a développé une pneumonie par aspiration pendant l'hospitalisation et est devenu dépendant de l'oxygène. Il n'y a pas eu d'amélioration significative de l'état clinique malgré 72 h de prise en charge médicale et une intervention chirurgicale a été recommandée. La laparotomie exploratrice a révélé une dilatation gastrique dans le sens inverse des aiguilles d'une montre et un volvulus. L'estomac a été repositionné en position anatomique normale et une gastropexie incisionnelle a été réalisée. Le chien a été maintenu en unité de soins intensifs pendant 4 jours après l'opération. Actuellement, 3 mois après l'opération, le chien est en bonne santé sans récidive des signes cliniques.Message clinique clé :La dilatation dans le sens inverse des aiguilles d'une montre et le volvulus gastriques sont une affection rare en médecine vétérinaire; cependant, cela doit être envisagé chez un patient présentant une distension gastrique aiguë et des signes d'obstruction de l'écoulement pylorique en l'absence de signes radiologiques caractéristiques de dilatation gastrique dans le sens des aiguilles d'une montre et de volvulus, et en cas de preuve radiologique de corps étranger gastrique persistant malgré la prise en charge médicale. Un diagnostic erroné de dilatation gastrique dans le sens inverse des aiguilles d'une montre et de volvulus peut retarder l'intervention chirurgicale définitive et entraîner une morbidité et une mortalité plus élevées.(Traduit par Dr Serge Messier).

Gastric volvulus and wandering spleen; a life-threatening surgical emergency.

Wandering spleen and gastric volvulus are two of the rarely encountered conditions occurring together with or without other congenital and acquired defects. These potentially fatal conditions originate from a shared cause, i.e. the defect of intraperitoneal ligaments resulting in a failure to withhold these organs at their anatomical position and alignment. This can come to attention in both childhood and/or adulthood, and the diagnosis calls for a high degree of suspicion and a failure to diagnose can culminate in death of both the organs, i.e. the spleen and stomach. We are presenting the case of a 20-year-old girl who underwent an emergency laparotomy for gastric volvulus and wandering spleen.

Cardiac Arrest Caused by an Acute Intrathoracic Gastric Volvulus Treated With Percutaneous Gastrostomy.

During cardiopulmonary resuscitation, one of the first priorities after establishing basic and advanced life support is to identify the cause of the arrest. We present a rare case of cardiac arrest due to a decreased venous return from mediastinal shift caused by a paraesophageal hernia with an incarcerated thoracic gastric volvulus, which was treated by percutaneous gastrostomy.

The role of percutaneous endoscopic gastrostomy in the treatment of acute gastric volvulus.

Gastric volvulus is an uncommon pathology that can occur acutely, in a chronic setting, or even as a casual finding. The primary kind occurs in 30% of patients. Secondary causes include hiatal hernia types II-III up to 70% of cases. The main treatment of acute gastric volvulus is gastric decompression, by means of a nasogastric tube (NGT) or endoscopy. However, it is not a procedure exempt from complications. Traditionally, definitive treatment involves surgery, consisting in hernia reduction with gastropexy/anti-reflux technique and/or hiatoplasty. We present the case of a 83-year-old woman with permanent atrial fibrillation, among other cardiovascular conditions.

Gastric volvulus: unraveling the diagnosis with MPRs.

Gastric volvulus is a rare entity with a spectrum of acute and chronic clinical presentations. Body radiologists must be cognizant of the subtypes of gastric volvulus and identify potential complications. Mortality can be high if unrecognized from gastric necrosis, perforation, and sepsis. CT with multiplanar reformations is critical for complete evaluation beyond radiography and fluoroscopy. This article reviews clinical and imaging features of uncomplicated and complicated gastric volvulus, with the aim of guiding appropriate management.

Transient distal renal tubular acidosis in a dog with gastric-dilatation-volvulus.

A case of distal renal tubular acidosis occurring as a transient complication in a 13-year-old female greyhound dog with gastric-dilatation-volvulus was diagnosed. The acute renal ischemia and inflammatory condition associated with this syndrome could be considered the main underlying mechanisms responsible for the acute, severe, and complicating renal tubular dysfunction.

Acidose tubulaire rénale distale transitoire chez un chien atteint de volvulus et de dilatation gastrique. Un cas d'acidose rénale distale se manifestant comme une complication transitoire chez une chienne Lévrier anglais âgée de 13 ans atteinte de dilatation gastrique-volvulus a été diagnostiqué. L'ischémie rénale aiguë et l'affection inflammatoire associées à ce syndrome pourrait être considérées comme les principaux mécanismes sous-jacents responsables de la dysfonction tubulaire rénale grave et complexe.(Traduit par Isabelle Vallières).

Role of Diagnostic Preoperative Upper Gastrointestinal Endoscopy in Radiologically Confirmed Gastric Volvulus.

BACKGROUND AND AIMS: Gastric volvulus (GV) is a life-threatening condition that warrants prompt diagnosis and treatment. GV is a radiologic diagnosis. The role of preoperative upper gastrointestinal endoscopy (UGIE) for individuals with radiologically confirmed GV is poorly defined. Our objective was to assess the diagnostic yield of UGIE in the preoperative evaluation of patients presenting with radiologically confirmed GV. METHODS: Retrospective review of all adult patients undergoing surgery for GV between July 1996 and August 2016 has been carried out. We performed analyses evaluating diagnostic yield of preoperative UGIE and compared outcomes in patients who did and did not undergo preoperative UGIE. Outcomes were diagnostic yield of preoperative UGIE, length of hospital stay, postoperative complications, and mortality at 30 days and 1 year. RESULTS: In the preoperative UGIE group, the diagnostic yield was 34.6% (27/78). The most common endoscopic findings were erosive esophagitis (13/27) and clean based gastric or duodenal ulcers (5/27). There were no cases of esophago-gastric malignancy. Three patients had ulcers with stigmata of recent bleeding, and three patients had features suggestive of gastric ischemia. Endoscopic findings did not influence surgical management. There was no statistically significant difference in mortality between patients who did and did not undergo preoperative UGIE, both at 30 days (0 vs. 2.5%) and 1 year (3.8 vs. 7.5%). CONCLUSION: Among patients with radiologically confirmed GV, preoperative UGIE rarely demonstrates clinically significant findings and can potentially delay definitive surgical intervention.

A rare cause of severe epigastric pain, emesis and increased lipase.

INTRODUCTION: Gastric volvulus is an uncommon, but severe pathology requiring early diagnosis and urgent treatment. Its atypical symptoms and rarity make it difficult to diagnose, possibly leading to delayed treatment and fatal complications. PATIENTS AND METHODS: We present a case of a 73-year-old patient with Parkinson's disease with complaints of severe epigastric pain, emesis and an increased lipase. RESULTS: Diagnosis of an organo-axial gastric volvulus was made. Treatment consisted of reduction of the volvulus by decompression via nasogastric tube. The underlying cause was a para-esophageal hernia that was repaired by Nissen-fundoplication later on. CONCLUSIONS: We describe symptomatology, diagnostic and therapeutic options of gastric volvulus.

Paraesophageal hernia and gastric volvulus: an uncommon etiology of vomiting and upper gastrointestinal bleeding.

The authors report the case of a 75 year-old woman admitted to the emergency room with abdominal pain and coffee ground vomiting. Marked epigastric distension with tenderness and signs of severe dehydration were present. Upper GI endoscopy showed a black esophagus covered by a large amount of dark fluid, diffuse hyperaemia and superficial erosions. Marked distortion of gastric anatomy caused by stomach rotation and a large paraesophageal hernia was observed and the pylorus was not identified. Chest X-ray and CT scan confirmed the presence of an organoaxial gastric volvulus with antero superior rotation and incarceration of the gastric antrum, which was located above the diaphragm. Immediate surgery repaired the diaphragmatic hernia, obtained volvulus reduction and a Nissen fundoplication was performed to prevent recurrence. The patient was discharged without further complications. Acute gastric volvulus is a rare entity that may manifest with vomiting due to gastric outlet obstruction and gastrointestinal bleeding associated with mucosal ischemia and sloughing. Emergency surgery wass required to resolve symptoms and prevent complications.

Does the addition of fundoplication to repair the intra-thoracic stomach improve quality of life?

BACKGROUND: The role of fundoplication in addition to hiatal hernia repair has been controversial. The aim of this study was to compare quality of life related to gastroesophageal reflux disease (GERD) in patients who underwent intra-thoracic stomach repair with and without fundoplication. We proposed that the group without a fundoplication would have poorer quality of life due to continued symptoms. METHODS: All patients undergoing foregut surgery at the Creighton University Esophageal Center are entered in a prospectively maintained database. The database was queried to identify patients who underwent surgery for a near complete (>75 % of stomach in chest) intra-thoracic stomach with gastric volvulus between 2004 and 2013. A questionnaire was derived from the Quality of Life in Reflux and Dyspepsia and Frequency Scale for Symptoms of GERD questionnaires to assess for symptoms related to reflux, and this questionnaire was administered by phone. RESULTS: A total of 150 patients underwent repair of ITS during the study period. A total of 109 patients had ITS repair with fundoplication, while 41 had only ITS repair. Follow-up was available in 54 % of patients in the fundoplication group (median follow-up of 5.2 years) and in 49 % of patients in the non-fundoplication group (median follow-up of 4 years). Significantly, more patients woke up at night (p < 0.01) and found themselves coughing around mealtime (p < 0.01) in the fundoplication group. Patients in the non-fundoplication group had significantly more daytime reflux (p = 0.02). Despite these symptoms, only one patient in the fundoplication group and no patients in the non-fundoplication group admitted that these symptoms were severe enough to severely affect their quality of life. All other patients contacted felt satisfied, and >80 % rated their quality of life as either good or excellent. CONCLUSIONS: We conclude that there is not a significant difference in quality-of-life parameters on long-term follow-up between patients undergoing ITS repair with or without fundoplication.

Hiatal hernia with upside-down stomach. Management of acute incarceration: case presentation and review of literature.

Upside-down stomach (UDS) represents the rarest type of hiatal hernia (<5%) and is characterized by herniation of the entire stomach or most gastric portions into the posterior mediastinum. We present here a very rare complication of such a condition which is incarceration of upside-down stomach. A 54 year-old female was admitted to the emergency department presenting signs of acute epigastric pain radiating into thorax. Computed tomography revealed a giant hiatal hernia with incarceration of the gastric trunk. Immediate operation for reduction of the incarcerated stomach and repair of the hiatal defect was performed. The patient was discharged without any complication and was followed up at the surgical outpatient department. The presented case confirms that differentiation of an acute epigastric or intrathoracic pain in adults should always exclude presence of hiatal hernia which in case of incarceration should be treated by prompt surgical management.

[The gastric volvulus as a cause of dyspnea. A case report]. / Vólvulo gástrico como causa de disnea. A propósito de un caso.

The gastric volvulus is a not very frequent entity that can show up in acute form or chronic. The acute volvulus can show up with the triad of Borchardt, the chronic one can be asymptomatic and its diagnosis is usually incidental. We present shows a case of an airplane pilot that presents dyspnea to the medium efforts with cough related with episodes of gastric acidity mainly after profuse foods. The diagnostic confirmation was carried out by means of radiological simple and contrasted studies. A surgical intervention was performed and the symptoms disappeared without other alterations in a period of pursuit of one year.

[Gastrointestinal tract volvulus: diagnosis and correlation between plain-film X-ray and multidetector computed tomography findings]. / Vólvulos del tracto gastrointestinal. Diagnóstico y correlación entre radiología simple y tomografía computarizada multidetector.

Gastrointestinal volvuli cause processes that manifest as acute abdomen. Volvuli are important not because they are common, but rather because their possible complications can be severe. All types of volvuli share a common pathophysiology, which consists of intestinal obstruction in a closed loop that results in ischemia. The clinical manifestations are nonspecific, so radiologists play a very important role in the early identification of the most common signs of torsion. These include the "bird's beak sign", the "whirlpool sign", and signs of potentially reversible or irreversible ischemia. The treatment of choice in most cases is surgery, either to correct the torsion and save the organ or to resect it if it is necrotic.