El vólvulo gástrico en la edad pediátrica: ¿cuándo sospecharlo y cómo manejarlo? / Gastric volvulus in children: when to suspect and how to manage

INTRODUCCIÓN Y OBJETIVO: El vólvulo gástrico es una entidad que puede manifestarse con un amplio espectro clínico, lo que puede llevar a un retraso en el diagnóstico y tratamiento. El objetivo de nuestro trabajo es definir los tipos de vólvulo gástrico, analizando los factores predisponentes, la clínica, los hallazgos radiológicos y el tratamiento de cada uno de ellos. MATERIAL Y MÉTODOS: Se realizó un estudio descriptivo retrospectivo de los vólvulos gástricos diagnosticados en un hospital terciario durante un periodo de 10 años (2006-2016). Se incluyeron 32 pacientes, que se clasificaron en tres grupos en función de la presentación clínica: 7 con la forma aguda, 12 con la forma crónica y 13 con la forma neonatal-lactante. Se recogieron datos epidemiológicos, clínicos, diagnósticos y de manejo de cada caso. RESULTADOS: El vólvulo gástrico órgano-axial fue el subtipo más frecuente al analizar la totalidad de los pacientes (81%), aunque en la presentación aguda el más prevalente fue el mesentérico-axial (86%). En la forma aguda, la clínica más frecuente fue los vómitos no biliosos (86%), siendo en la forma crónica la sintomatología más variada. El diagnóstico se realizó con tránsito gastroduodenal en la mayoría de los casos. Las opciones de tratamiento fueron cirugía o medidas conservadoras, en función del tipo de vólvulo gástrico. CONCLUSIONES: Existen distintas formas de presentación del vólvulo gástrico (aguda, crónica, neonatal-lactante), cada una con una sintomatología y manejo diferentes. Dada la clínica inespecífica, es importante conocer los factores predisponentes y los hallazgos que aumentan su sospecha en la radiografía. La prueba de elección para su diagnóstico es el tránsito gastroduodenal

INTRODUCTION AND OBJECTIVE: Gastric volvulus is an entity with a broad clinical spectrum, which can lead to a delay in diagnosis and treatment. The purpose of this study is to define the types of gastric volvulus, analyzing the predisposing factors, clinical, radiological findings and treatment of each one. MATERIALS AND METHODS: A retrospective, descriptive study of the gastric volvulus diagnosed at a tertiary hospital was carried out during a period of 10 years (2006-2016). Thirty-two patients were included, which were classified into three groups according to the clinical presentation: 7 with the acute form, 12 with the chronic form and 13 with the neonatal form. Epidemiological, clinical, diagnostic and management data were collected for each case. RESULTS: Organo-axial gastric volvulus was the most frequent subtype of all the sample (81%), although in the acute presentation, the most prevalent subtype was the mesentero-axial (86%). In the acute form, the most common symptom was non-bilious vomiting (86%), whereas in the chronic form the clinical presentation was more varied. The diagnosis was made with upper gastrointestinal series in most cases. Surgical or conservative treatment were chosen depending on the type of gastric volvulus. CONCLUSIONS: There are different forms of presentation of gastric volvulus (acute, chronic, neonatal), with different clinical features and implications with respect to treatment options. Due to its nonspecific clinical presentation, it is important to know the predisposing factors and the common radiological findings highly suggestive of the diagnosis. An upper gastrointestinal series is the study of choice for its diagnosis

Nonsurgical endoscopic treatment of gastric volvulus in extremely high-risk surgical patients.

Gastric volvulus is a rare entity that occurs as a consequence of a rotation of the stomach of more than 180°, with gastric outlet obstruction and vascular compromise. It occurs secondary to diaphragmatic defects in most cases and is mainly reported in elderly patients who are fragile and present severe associated comorbidities. Here we present a nonsurgical treatment with the use of a single percutaneous endoscopic tube to perform gastropexy in patients with a high risk for surgery or inoperable patients. We present two cases that show that this therapeutic option is viable, with acceptable results under very specific clinical conditions.

Paediatric abdominal compartment syndrome and shock associated with gastric volvulus improved rapidly by gastric suction in the emergency department.

Abdominal compartment syndrome (ACS) is not rare and has a high mortality in the paediatric intensive care unit. However, there are few reports about this in the emergency department (ED). We report an 8 month-old male patient with ACS in shock associated with gastric volvulus who improved rapidly by a simple procedure in the ED. He had congenital comorbidities, including multiple cranial anomalies and was transferred because of decreased mental status. He had compensated shock with cold and mottled skin of the lower extremities, paediatric Glasgow Coma Scale of E3V5M6 and prominence of the left upper abdomen. The abdominal X-ray showed a considerably distended stomach. Soon after aspiration of gastric contents, shock and mental status improved. Physicians should consider ACS in the differential diagnosis of shock with abdominal distention. ACS may be ameliorated by gastric suction. Gastric volvulus can induce shock and decreased mental status, particularly in patients with comorbidities.

Bochdalek hernia and intrathoracic ectopic kidney: Presentation of two case reports and review of the literature.

Bochdalek hernia is a congenital abnormality with high morbidity and mortality characterized by passage of the abdominal organs into the thoracic cavity through a diaphragmatic defect. Intrathoracic location of abdominal organs such as kidneys is very rare, with a reported incidence of only 0.25% in the literature. Herein, we present two cases of Bochdalek hernia with a herniation of intra-abdominal organ such as kidney that was treated in our clinic and compare this rare case with those in the literature. In both cases, the functionally normal kidneys were left in situ during diaphragmatic repair. No complications were observed during the postoperative period, and 10- and 1-year follow-ups. In cases with Bochdalek hernia associated with an intrathoracic ectopic kidney, the functionally normal ectopic kidneys were left in situ during repair of the diaphragmatic defect without complications.

Prehospital Care of Canine Gastric Dilatation and Volvulus.

The intent of the Operational K9 (OpK9) ongoing series is to provide the Special Operations Medical Association community with clinical concepts and scientific information on preventive and prehospital emergency care relevant to the OpK9. Often the only medical support immediately available for an injured or ill OpK9 in the field is their handler or the human Special Operations Combat Medic or civilian tactical medic attached to the team (e.g., Pararescueman, 18D, SWAT medic). The information is applicable to personnel operating within the US Special Operations Command as well as civilian Tactical Emergency Medical Services communities that may have the responsibility of supporting an OpK9.

[A case of adult gastric volvulus treated using upper gastrointestinal series].

Here, we report a case of adult gastric volvulus that was treated using an upper gastrointestinal series and provide a review of relevant reports. A 55-year-old woman presented with upper abdominal pain. Abdominal computed tomography revealed mesenteroaxial gastric volvulus. We performed an upper gastrointestinal series after the placement of a nasogastric tube. We successfully performed detorsion by repositioning. There was no recurrence of gastric volvulus after the detorsion. However, considering the risk of recurrence, we also performed laparoscopic gastropexy. The postoperative course was uneventful, and she was discharged from the hospital on postoperative day 3. No recurrence of symptoms has been observed to date.

Large Paraesophageal Hiatus Hernia: Is Surgery Mandatory?

Purpose/Aim: Paraesophageal hiatus hernias are seldom found, however the incidence is increasing accounting for 5-10% of all hiatal hernias. The aim of this review is to emphasize controversies in clinical presentation, essential workup investigations and highlight non-surgical and surgical management options. Materials and Methods: A PubMed literature search using the keywords "large or giant paraesophageal hernia", "hiatus or hiatal hernia", "laparoscopic surgery", "antireflux surgery", "mesh", "gastric volvulus" and "diaphragmatic hernia" published between 1998 until 2017 was conducted. Results: Presenting symptoms are non-specific and can be erroneously attributed to various more common medical conditions. Significant complications as gastric volvulus and stomach necrosis, may occur and the obscured clinical presentation can be confusing for the clinician. Management options in the elective setting are controversial, and surgical repair cannot be easily justified for a minimally symptomatic condition, especially in an elderly and perhaps frail patient. However, in the era of laparoscopic surgery around the hiatus, reduced operative stress makes surgical repair appealing in the elective setting. Surgical matters as the adjunct of an antireflux procedure or not, the use of prosthetic mesh to reinforce the hiatus, gastropexy and the clinical importance of radiological or endoscopic recurrence are still under debate. Conclusions: The laparoscopic treatment of paraesophageal hiatus hernias is effective with low morbidity rates, offered in symptomatic patients and good operative risk asymptomatic individuals. More studies are needed to assess improvement suggestions, as the use of prosthetic mesh or gastropexy, regarding complications and recurrence risks.

Thymoma with acute gastric volvulus: a case report.

BACKGROUND: Acute gastric volvulus (GV) is a rare disease with high mortality rate often associated with anatomic abnormalities. Thymoma is the most common neoplasm located in the anterior mediastinum. There is no reported relationship between thymoma and GV. Here we reported a case of thymoma with initial symptom of acute gastric volvulus. CASE PRESENTATION: A 43-year-old man complained of postprandial abdominal pain, nausea and vomiting. Acute gastric volvulus was diagnosed by chest radiograph, upper digestive tract radiograph and CT scan; later type B3 thymoma was diagnosed by biopsy of mediastinal mass. We inferred that gastric volvulus was secondary to thymoma due to phrenic nerve palsy. The patient was treated with endoscopic de-rotation. Further radiotherapy and chemotherapy were given. During treatments, GV still occurred with less severity and a reduced frequency of approximately every three to four months. CONCLUSION: We report the first case of thymoma initially presented with acute GV. We suspect a pathological mechanism related to the phrenic nerve palsy. This case indicates that thymoma may present alongside rare acute GV.

Food engorgement in 35 dogs (2009-2013) compared with 36 dogs with gastric dilation and volvulus.

The clinical features and management of food engorgement (FE) in dogs have not been previously described. This retrospective observational study describes characteristics and outcome of 35 dogs with FE, and compares features on presentation to 36 dogs with gastric dilation and volvulus (GDV). Cases were retrospectively reviewed for history, clinical findings and outcome. Gastric distension was measured by caudal gastric margin (CGM), level with lumbar vertebrae, on a lateral abdominal radiograph. Frequent characteristics of dogs with FE included tachycardia, tachypnoea, hyperproteinaemia, increased base excess (BE), mild hypernatraemia and hyperlactataemia. There was overlap in CGM between dogs with GDV (CGM range L3 to >L6) and dogs with FE (CGM range

Vólvulo de vesícula biliar en una anciana / Gallbladder volvulus in an elderly

Se presenta el caso clínico de una anciana de 94 años de edad con antecedentes de litiasis vesicular, quien acudió al Hospital General Docente Dr Juan Bruno Zayas Alfonso por presentar dolor abdominal de pocas horas de evolución acompañado de algunos vómitos biliosos y sensación de escalofríos ocasionales. Al examen abdominal se palpa una tumoración redondeada de alrededor de 6 cms, que se encuentra casi a nivel del flanco derecho. Fue intervenida de urgencia y se encontró la vesícula biliar gangrenosa por un vólvulo total del órgano. Se realizó colecistectomía convencional y la paciente tuvo una evolución favorable

The case report of a 94 years elderly with history of gallbladder lithiasis is presented. She went to Dr Juan Bruno Zayas Alfonso Teaching General Hospital due to an abdominal pain with a course of few hours along with some billiary vomits and sensation of occasional shivering. A round tumour of about 6 cms was found in the abdominal test, almost at the level of the right side. She was operated as an emergency and gallbladder was found gangrenous due to a total volvulus of the organ. A conventional cholecystectomy was carried out and the patient had a favorable clinical course

Vólvulo gástrico, causa infrecuente de dolor abdominal agudo / Gastric volvulus, an infrequent cause of acute abdominal pain

El vólvulo gástrico (VG) se caracteriza por la rotación anormal de una porción del estómago alrededor de un eje -horizontal o vertical- que puede ocasionar obstrucción, compromiso vascular e incluso estrangulación, pudiendo evolucionar a necrosis e incluso perforación. Se puede clasificar de acuerdo a su etiología, en primario o secundario, de acuerdo a su anatomía en órgano-axial o mesentérico-axial y de acuerdo a su presentación en crónico o agudo. Ambos tipos de vólvulos requieren de tratamiento, sin embargo, a pesar de que el tratamiento clásico ha sido la cirugía abierta, no existe un tratamiento estándar, ni consenso sobre la alternativa de elección en la actualidad. Las técnicas de mínima invasión, bien sean endoscópicas o laparoscópicas, deben ser consideradas en los pacientes de edad avanzada y alto riesgo quirúrgico en quienes se busca disminuir la morbilidad y mortalidad perioperatoria (AU)

Gastric volvulus (GV) is characterized by the abnormal rotation of a portion of the stomach around a horizontal or vertical axis that can cause obstruction, vascular disorder and even strangulation, and may evolve into necrosis or even perforation. It can be classified according to its aetiology into primary or secondary GV, according to its anatomy into axial organ or into axial mesenteric GV, and according to its presentation into chronic or acute GV. Both types of volvulus require treatment; however, in spite of the classic treatment being open surgery, there is no standard treatment, nor is there consensus on the alternative of choice at present. Minimally invasion techniques, whether endoscopic or laparoscopic, should be considered in patients of advanced age or high surgical risk, where what is sought is a reduction in perioperative morbidity and mortality (AU)

A case of upside-down stomach that was effectively treated by postprandial repositioning.

An 88-year-old woman with a history of stomach perforation and lumbar compression fracture was admitted to our hospital with a chief complaint of continuous vomiting, which she had experienced since the previous day. She showed vomiting, spontaneous pain and tenderness from the epigastric fossa through the left flank. In addition, she had marked kyphosis. On a CT scan, although the fornix was located in the abdominal cavity, the antrum and body had escaped into the thoracic cavity. A large volume of gastric content was observed. The patient was diagnosed with upside-down stomach from gastric volvulus and a hiatal hernia. Although we recommended surgery, the patient and her family did not agree with it. Thus, conservative therapy was selected. The patient's symptoms showed a significant improvement after the placement of a nasogastric tube, fasting and fluid therapy. After stabilization, an endoscopic examination was performed. The release of the gastric volvulus was confirmed and the nasogastric tube was removed. We instructed the patient to perform postprandial repositioning, which was based on the running shape of the digestive tract with the goal of achieving the passage of food and preventing a relapse of vomiting. The patient was instructed to first place herself in the right lateral decubitus position and then the prone position after eating. There was no recurrence of vomiting after the patient resumed eating. She was therefore discharged from our hospital. Upside-down stomach is usually an indication for surgery. However, in elderly patients, the fixation of the stomach to the abdominal wall has been reported to occur after endoscopic reduction, and conservative treatment was thus selected in this case.We herein reported a case in which postprandial repositioning was used to treat upside-down stomach.

The threatened stomach: management of the acute gastric volvulus.

INTRODUCTION: Acute presentation of gastric volvulus is a rare condition with a high mortality for acute ischaemia. This study was undertaken to investigate the acute management, diagnosis, and long-term outcomes of patients presenting with acute gastric volvulus. METHODS: Cases were reviewed retrospectively from 2004 to 2014. Patients presenting as an emergency admission with acute gastric volvulus were included. RESULTS: Thirty-six patients were included, five of whom had previous surgery. The mean age was 71 years old. All patients presented with vomiting and chest/epigastric pain. CT was diagnostic in all 26 patients. Barium swallow was diagnostic in two/four patients. OGD was diagnostic in 9 of 20 patients. All patients had an NG tube placed, and eight patients were treated conservatively and made a full recovery. Twenty-nine patients proceeded to surgery. Nine had a laparoscopic repair with two open conversions. Four patients had gastric necrosis, and all had open surgery with resection. Three patients had a mediastinal perforation, and one patient required an additional thoracotomy. All patients with viable stomach had a hiatal repair (where appropriate), 11 had a gastropexy, and 11 had a fundoplication. Mortality for gastric necrosis/perforation was 30 %. Mean postoperative stay was 4 days for laparoscopic repair and 8 days for uncomplicated open surgery. Nine of twenty-nine had transient dysphagia postoperatively. Three of eight patients treated conservatively had an elective procedure subsequently. CONCLUSIONS: Acute paraoesophageal hiatus hernia requires early resuscitation and diagnosis. CT should be favoured in assessment, and an NG tube placed promptly. A conservative management may be considered safely in stable patients. Surgical management should be prompt for unstable patients. Gastric ischaemia or perforation has a mortality of 30 %. Laparoscopic repair has a shorter postoperative stay, but has a higher recurrence rate. Surgery for patients without gastric ischaemia has good long-term outcomes with minimal morbidity.

Laparoscopic repair of Bochdalek hernia with intrathoracic kidney in a 2-year-old child.

Intrathoracic kidney with Bochdalek hernia is a very rare congenital anomaly. Some case reports have discussed repair by laparotomy or thoracotomy. We report a case in a child performed using a laparoscopic approach. A 2-year-old boy arrived at our hospital with gastric volvulus caused by a left-sided Bochdalek hernia. CT also showed a left-sided intrathoracic kidney. After conservative therapy for the volvulus, laparoscopic repair of the diaphragmatic hernia was performed. The key problem during the operation was the presence of the intrathoracic kidney. If direct closure of the hernia had been performed without the intrathoracic kidney having been relocated to the abdomen, a complete closure would have been impossible because of the renal vessels. After the intrathoracic kidney was relocated to the abdomen, the diaphragmatic defect was closed. The boy has been doing well without complications for 5 years, and CT reveals that the left-sided kidney is almost normally positioned.