Acute gastric volvulus

Abstract

An 18-year-old man presented with complaints of sudden onset pain in the epigastrium radiating to the left lower chest, starting 7 days prior followed by non-productive and persistent retching. On examination, the patient had a tachycardia (pulse rate 108 beats/min) and a blood pressure of 102/66 mmHg. His respiratory rate was 22 breaths/min and was afebrile. On chest examination, air entry was markedly reduced on the left side. The abdomen was not distended; an ovoid-shaped tender organ was felt in the epigastrium. The rest of the abdominal examination was normal. A single gentle attempt of nasogastric tube insertion was done, but insertion beyond the first mark was not possible. A plain X-ray study of the chest and abdomen done earlier showed a double bubble sign (Fig. 1), Contrast films showed a dilatated and tortous dumbbell-shaped stomach overlapping the left lower chest (Fig. 2). Although a computed tomography (CT) scan of the abdomen would have been preferable, the barium study had been done before the patient was referred to us [1]. In view of these findings a diagnosis of gastric volvulus with herniation into the left chest cavity was made, and the patient was urgently operated upon after appropriate preparation. The operative findings revealed that the left lobe of the liver and spleen were shifted medially and downwards so that the spleen was lying in the epigastrium (Fig. 3). The stomach was largely missing from the abdomen, and only a small pouch of fundus was visible just below the spleen. The entire distal stomach had herniated through a defect in the diaphragm posterolaterally on the left side. On needle aspiration about 500 ml of barium mixed fluid came out from the stomach pouch, but the stomach still refused to come down into the abdomen. So a thoracotomy was performed by extending the upper end of the laparotomy incision into the left side of the chest and the diaphragm was incised up to the defect posteriorly. The stomach was reduced into the abdominal cavity. It was viable, but inflammed and ballooned out with rotation of [180 anticlockwise (Fig. 4). It was derotated, and emptied by Ryle’s tube aspiration. A gastropexy was done. The defect in the diaphragm was repaired with nonabsorbable sutures, and all the incisions were closed after placing a thoracostomy tube to drainage. The patient improved in the postoperative period, and was discharged on the seventh postoperative day. The normal stomach is stabilised and prevented from twisting into a volvulus by the ligamentous supports, i.e. the gastrohepatic, gastrocolic, oesophagophrenic and gastrosplenic ligaments. The relative fixity of the pylorus and gastro-oesophageal junction also helps to maintain the normal position of the stomach. A volvulus can occur when these attachments are lax or absent. It may also occur secondary to adjoining structural defects like congenital diaphragmatic hernia, hiatus hernia, eventration of diaphragm, paraoesophageal hernia, splenomegaly, or gastric outlet obstruction [2]. Gastric volvulus is classified into three types: organoaxial: the stomach rotates around a longitudinal axis between the gastro-esophageal junction and the pylorus. This is the most common type occurring in approximately 59% of cases, and is usually associated with A. Hai S. Goel S. Shahab S. Kumar Department of Surgery, University College of Medical Sciences and Associated GTB Hospital, University of Delhi, Delhi, India