Case Report

Full text online at http://www.jiaps.com

Acute gastric volvulus secondary to eventration of the diaphragm in a

child
A. K. Singal, K. G. Vignesh1, J. Matthai2
Departments of Pediatric Surgery, 1General Surgery and 2Pediatrics, PSG Institute of Medical Sciences,

Peelamedu, Coimbatore, Tamilnadu, India

Correspondence: A. K. Singal, Department of Paediatric Surgery, PSG Institute of Medical Sciences, Peelamedu, Coimbatore,

Tamilnadu 641 004, India. E-mail: arbinders@yahoo.com

ABSTRACT
We report an 18-month-old boy who presented with acute organoaxial volvulus of stomach secondary to eventration of diaphragm.
Clinically, the child exhibited classical triad of epigastric distension, unproductive retching and inability to pass a nasogastric tube.
Successful operative management is presented and relevant literature is discussed.
KEY WORDS: Eventration diaphragm, gastric volvulus, paediatric

Acute gastric volvulus is an uncommon condition and

more so in the paediatric age group. Rotation of the
stomach results in partial or complete obstruction at the
inlet as well as the outlet and compromise of the
vascularity. Early diagnosis is critical and prompt surgical
intervention is required to prevent gastric necrosis and
perforation. Gastric volvulus may be idiopathic or
secondary to various congenital or acquired conditions.
Among the associated problems diaphragmatic defects
predominate.[1-4] We herein report an 18-month-old child
who presented with acute gastric volvulus associated with
eventration of left hemidiaphragm which was managed
successfully.
CASE REPORT
An 18-month-old male child presented with sudden onset
nonbilious vomiting, abdominal pain and upper
abdominal distension for 3 days duration. The initial
vomitus was ingested food and after that the child had
unproductive retching. He no significant past history. The
referring doctor had tried to insert a nasogastric tube but
had failed.
On examination the child had mild pallor and
moderate dehydration. There was visible fullness in
the epigastrium and umbilical region. Nasogastric
tube could not be passed into the stomach. In view
of evident Borchardts triad (Retching, upper
ab domin al diste nsi o n a nd i na b i li ty to pa s s
J Indian Assoc Pediatr Surg / Jan-Mar 2006 / Vol 11 / Issue 1

nasogastric tube) acute gastric volvulus was

suspected. [5] Supine X-ray of the abdomen showed
grossly distended stomach and paucity of distal gas.
Erect X-ray showed distended stomach with an air
fluid level and a notch on the right border [Figure
1]. The left hemidiaphragm was raised and left
eventration was suspected. A barium swallow showed
obstruction in the lower end of esophagus with bird
beak picture.
After adequate fluid resuscitation, the child was taken
up for laparotomy. Left subcostal incision was taken and
grossly distended stomach was seen bulging out.
Attempt to pass a nasogastric tube failed again. A wide
bore needle was inserted and stomach was decompressed
and 500 ml of light brown fluid and lot of air was
aspirated. Organoaxial volvulus was noted and
derotation was done. Nasogastric tube could be passed
easily now. Spleen and colon were seen to lie high up
into the chest against the eventrated diaphragm. The
eventration was segmental and was confined to the
posterior half and dome of the diaphragm. The colon
was dissected free from the diaphragm and the thinned
out diaphragm was plicated with rows of 3-0 prolene
sutures placed in anteroposterior axes [Figure 2].
Anterior gastropexy was done fixing the stomach at 3
points to the anterior abdominal wall. Postoperatively
child was kept nil per orally for 3 days and was discharged
uneventfully on day 5. He has remained asymptomatic
at 3 months follow-up.
44

Singal AK, et al: Acute gastric volvulus to eventration of the diaphragm

Figure 1a: Erect X-ray of the abdomen showing distended stomach

with air fluid level and a notch in the right border, paucity of gas in the
intestine, elevated left hemidiaphragm and mediastinal shift to right;
Figure 1b: Operative photograph showing distended stomach and
eventrated diaphragm.

Figure 2a: Operative photograph showing repaired plicated

diaphragm; Figure 2b: Postoperative X-ray showing normal contour
of the diaphragm and normal mediastinal location.

DISCUSSION

nasogastric tube. The features result from dual

obstruction at the gastroesophageal and pyloric ends. This
triad may be seen upto 30% in adults and rarely in
children.[2] Although, one or more of these criteria may
be seen in 70% of the children. [2,4,5] In most of the pediatric
cases reported in literature, it has been possible to place
a nasogastric tube into the stomach,[4,6] but in the present
case, the classical Borchardts triad was seen and repeated
attempts at nasogastric tube insertion had failed and it
was easily passed once the stomach was derotated in
operation theatre. A word of caution may be exercised
during insertion of nasogastric tube as perforation of
stomach has been reported due to overzealous attempts
at nasogastric tube insertion.[2] The children may also
present with chronic symptoms like vomiting, abdominal
distension and failure to thrive due to intermittent or
chronic gastric volvulus.[2,6]
The radiological findings are specific in acute and
secondary gastric volvulus. Plain film in acute organoaxial
volvulus shows a distended stomach with an airfluid level
and paucity of distal intestinal gas. There may be notch
seen on the right border with concavity to right side which
is considered to be specific for organoaxial volvulus.[2,5,7]
Barium swallow may show obstruction at the
gastroesophageal junction with a Birds beak appearance.
It is important to look for associated defects like
diaphragmatic defects as they may be the predisposing
cause for volvulus in upto 60% of the cases. In the present
case, eventration of the left side was suspected on the
preoperative X-ray.

The normal stomach is fixed and prevented from

abnormal rotation by the four attachments namely
esophageal hiatus, gastrophrenic ligament, gastrosplenic
ligament and duodenum. A normal diaphragm also serves
to prevent abnormal displacement of abdominal viscera
and gastric volvulus. Absence or attenuation of these
anatomic factors or excessive mobility due to wide
subdiaphragmatic space predisposes to gastric volvulus.
The stomach can undergo volvulus either in the
Organoaxial (along the long axis of the organ) or
mesenterioaxial predisposition.[2,4] Organoaxial volvulus
is less common in children and is often seen in association
with other predisposing anomalies like eventration,
diaphragmatic hernia, hiatus hernia, asplenia, lack of
ligaments etc.[1-4] Given the rarity of the problem and
unusual presenting features, the diagnosis may be
difficult.

Acute gastric volvulus is a surgical emergency and delay

in recognition and treatment can cause strangulation and
perforation of stomach. Management includes trial of
decompression via nasogastric tube while providing fluid
resuscitation. If it fails patient should be hurried for
surgery. Surgery involves decompression, derotation, repair
of the co-existing anomaly if any and anterior gastropexy.
Even after the correction of underlying defects, most of
the authors in literature have elected to pex the stomach
also. [2,6] Anterior gastropexy supplemented with a
gastrostomy has also been described but has the
disadvantage of a gastrostomy tube which we think can
be avoided.[3] It is not only unnecessary but also may lead
to complications.

The clinical symptoms depend on the extent or degree of

rotation and gastric outlet obstruction. Children with
organoaxial volvulus often present acutely and may
exhibit classical triad of Borchardt epigastric distension,
violent unproductive retching and inability to pass a

In conclusion, acute gastric volvulus though rare should

be suspected in any child with unproductive retching,
abdominal distension and inability to pass a nasogastric
tube. Early diagnosis and timely surgery have gratifying
outcome.

45

J Indian Assoc Pediatr Surg / Jan-Mar 2006 / Vol 11 / Issue 1

Singal AK, et al: Acute gastric volvulus to eventration of the diaphragm

REFERENCES

4.

1.

5.

2.

3.

McIntry RC, Bensard DD. The pediatric diaphragm in acute gastric

volvulus. J Am Coll Surg 1944;178:234-8.
Mayo A, Erez I, Lazar L, Rathaus V, Konen O, Freud E. Volvulus of
the stomach in childhood: spectrum of the disease. Pediatr Emerg
Care 2001;17:344-8.
Karande TP, Oak SN, Karmarkar SJ, Kulkarni BK, Deshmukh SS.
Gastric volvulus in childhood. J Postgrad Med 1997;43:46-7.

J Indian Assoc Pediatr Surg / Jan-Mar 2006 / Vol 11 / Issue 1

6.
7.

Miller DL, Pasquale MD, Seneca RP, Hodin E. Gastric volvulus in

the pediatric population. Arch Surg 1991;126:1146-9.
Borchardt M. Zur Pathologie and Therapie des magenvolvulus. Arch
Klin Chir 1904;74:243-60.
Darani A, Mendoza-Sagaon M, Reinberg O. Gastric volvulus in
children. J Pediatr Surg 2005;855-8.
Andiran F, Tanyel FC, Balkanci F, Hicsonmez A. Acute abdomen
due to gastric volvulus: diagnostic value of a single plain radiograph.
Pediatr radiol 1995;25:S240.

46