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Tropical 2010;31(4):341–344 neurological disorders will require a feeding jejunostomy. In Acute gastric and advanced cases surgery remains the only option with resection of the necrosed segment and reconstruction by anastomosing following abdominal the esophageal end to the remaining or the . trauma in a case of eventration of Even in cases where early surgery is undertaken there is a reported mortality of 50-60%.2 diaphragm

MAJ. N TIWARI1 Introduction BRIG. AK SHARMA2 LT. COL. A GALAGALI3 We present a where mesenteroaxial with acute WG. CDR. M KUMAR3 pancreatitis presented as an epigastric lump following MAJ. K CHAND4 abdominal trauma in a child with occult left sided eventration of diaphragm. This case is worth reporting due to its rarity and Military Hospital, CTC, Pune1, to emphasize the wide range of rare presentation that Army Hospital (R&R) New Delhi2, eventration of diaphragm can produce. Armed Forces Medical College, Pune3, Military Hospital, Meerut4 Case report

Correspondence: Wing. Cdr. Manoj Kumar A 6 year old female child presented to pediatric emergency Reader, Dept of Surgery with hemodynamic instability following blunt trauma to the Armed Forces Medical College upper abdomen 4 days back, due to fall over a stone while Wanowrie PO, Pune – 411040, India. playing. There was history of violent cough following the Email: [email protected] trauma. Two days after the trauma she developed respiratory distress, abdominal distension and coffee ground . References Abdominal distension was confined to upper abdomen. There was history of for 4 days. There was no history of 1. Todd SR, Marshall GT, Tyroch AH. Acute gastric dilatation or urinary symptoms. No past history of abdominal or revisited. Am Surg. 2000;66:709–10. respiratory problems. Pediatricians made a clinical diagnosis 2. Adbu RA, Garritano D, Culver O. Acute gastric necrosis in of traumatic liver hematoma and pediatric surgical consultation Anorexia Nervosa and Bulimia. Arch Surg. 1987;122:830–2. was sought. General physical examination revealed pallor, 3. Turan M, Sen M, Canbay E, Karadayi K, Yildiz E. Gastric necrosis severe dehydration, tachycardia with low volume pulse and and perforation caused by acute gastric dilatation: report of a tachypnea. Heart sounds were normal but left basal air entry case. Surg Today. 2003;33:302–4. was grossly diminished. Abdominal examination revealed a 4. Bortul M, Scaramucci M, Tonello C, Spivach A, Liguori G. Gastric soft, tender and resonant epigastric mass with no visible wall necrosis from organoaxial volvulus as a late of peristalsis. Digital rectal examination was normal. The child laparoscopic gastric banding. Obes Surg. 2004;14:285–7. was resuscitated and investigated with a presumptive 5. Michel LA, Buche M, de Canniere L, Chenu P. Gastric volvulus diagnosis of traumatic pseudocyst of the pancreas. However after coronary bypass. Lancet. 1997;349:251. passing a nasogastric tube was difficult, and had to be 6. Wharton RH, Wang T, Graeme-Cook F, Briggs S, Cole RE. Acute manipulated 4 times before 900 ml of coffee ground fluid could idiopathic gastric dilation with gastric necrosis in individuals with be aspirated. Erect X-ray abdomen (AXR) showed abnormal Prader-Willi syndrome. Am J Med Genet. 1997;73:437–41. course of the nasogastric tube from anterior to posterior 7. Chaun H. Massive gastric dilatation of uncertain etiology. CMAJ. direction with tip reaching the left subcostal area (Figure 1A). 1969;100:346–8. There were two air fluid levels in left upper quadrant with no 8. Byrne JJ, Cahill JM. Acute gastric dilatation. Am J Surg. distal bowel gas. The left hemidiaphragm was intact but highly th 1961;101:301–9. placed at the level of 5 rib, and there was no 342 Tropical Gastroenterology 2010;31(4):341–344 . All these suggested left sided eventration lying low and anterior to suggestive of mesenteroaxial of diaphragm. The soft epigastric lump with difficulty in passing gastric volvulus. Hemogram and renal parameters were normal nasogastric tube and coffee ground aspirate made us to think but serum potassium was low (3.1 mmol/L). The serum amylase in terms of associated gastric volvulus also. Ultrasonogram of was high 324 IU/L (3-13 IU/L). After adequate resuscitation a abdomen showed dilated stomach with full of fluid and food left upper transverse laparotomy was performed. There was debris with edematous wall. Other visceral organs were normal about 50 ml of hemorrhagic free fluid in the peritoneal cavity. and pancreas was obscured by bowel gas. It also demonstrated Stomach was grossly dilated and twisted parallel to the paradoxical movement of the left hemi diaphragm confirming mesenteric axis with pylorus lying high and posterior in the left eventration. Hence, the diagnosis of acute gastric volvulus upper quadrant. GE junction was at a lower level and anteriorly with eventration was considered a high possibility. Gastro- placed. However, the stomach was viable without any esophagogram (Figure 1B) with water soluble contrast showed (Figure 2A) and the greater omentum showed multiple chalky pylorus to be posterior and highly placed with GE junction white nodules of fat necrosis (Figure 2B). Pancreas was

Figure 1: 1A) Plain abdominal reveals abnormal course of nasogastric tube with two air fluid levels in the gastric region and paucity of distal gas, 1B) Upper GI contrast study showing mesentero-axial volvulus of stomach.

Figure 2: 2A) Per-operative photo showing mesentero-axial volvulus of stomach and 2B) shows fat necrosis of omentum suggestive of pancreatitis. Case Report 343

differential diagnosis can vary drastically. Probably diaphragmatic anomalies complicate this clinical scenario more than any other anomaly as they can change the anatomy and physiology of not only abdominal viscera but also the thoracic. Plain X – ray abdomen with both domes of diaphragm plays a pivotal role in any abdominal symptomatology, which in our case has made us to diagnose more than what we were dealing with. Left sided diaphragmatic eventration on X-ray has led us to the accurate diagnosis and appropriate management. Eventration of diaphragm is a common condition with an incidence of 1 in 10,000. Many remain asymptomatic and often Figure 3: Histopathology of omental biopsy showing mismanaged. There are two types of eventration namely saponification confirming pancreatitis congenital (paralytic & non paralytic) or acquired. Usually it located slightly high and more towards left hemidiaphragm presents with respiratory or GIT symptoms. Congenital with a bulky and edematous head. The left hemidiaphragm was diaphragmatic (CDH) has been known to cause several thinned out, floppy and highly placed. All the 4 gastric rare abdominal complications like incarceration or strangulation ligaments were unduly lax. Pylorus, spleen and pancreatic tail of either small or large bowel, acute associated were lying in the space created by eventration. The stomach with malrotation, splenic torsion, and gastric volvulus either was derotated, contents of the left upper quadrant reduced organo-axial or mesentero-axial with or without perforation.1-4 into the abdominal cavity. Plication of left hemidiaphragm was Similarly, eventration of diaphragm can also predispose to done with 2-0 prolene interrupted horizontal mattress sutures several an abdominal complication amongst which gastric till adequately flattened. Division of gastrocolic ligament and volvulus is common. Gastric volvulus an uncommon condition anterior gastropexy by tube gastrostomy was done for volvulus and more so in the pediatric age is rotation of all or part of the to prevent recurrence. Peritoneal and lesser sac drains were stomach by more than 180º, which may lead to a closed-loop placed for pancreatitis and a biopsy was taken from the obstruction and possible strangulation.5 Gastric volvulus may omentum. Postoperative recovery was uneventful. Gastrostomy be idiopathic or secondary to various congenital and acquired was removed after 2 weeks. Post operative chest X-ray and conditions. Among the associated problems diaphragmatic upper gastrointestinal contrast study showed adequate defects predominate. Stomach is held in its normal position by flattening of the diaphragm and normal alignment of the its natural ligaments, namely, gastrohepatic, gastrophrenic, stomach. The biopsy of the omentum confirmed the pancreatitis gastrosplenic and gastrocolic ligaments.5 Since these ligaments by showing soonification changes (Figure 3). The child are related to diaphragm, spleen and colon; any problems of recovered well and there is no recurrence of pancreatitis in 6 these ligaments as such or the adjacent organs can produce months follow-up. volvulus. Not infrequently, gastric volvulus in children fails to exhibit the full gamut of such as abdominal Discussion distension, vomiting, pain, and . Borchardt described the classical triad of severe epigastric pain, retching or vomiting Abdominal trauma has been known for long in bringing occult and inability to pass nasogastric tube.6 However, one need not disease to notice. Until otherwise proved, pancreatic find the classical triad in all the cases. For these reasons, pseudocyst becomes an obvious diagnosis in an epigastric symptomatic gastric volvulus in infancy and childhood may swelling following upper abdominal trauma. The differential not be as rare as is commonly assumed and early diagnosis diagnosis in such situation includes parietal hematoma, and prompt surgical intervention is required to prevent gastric hematoma of left lobe of liver, organized collection in lesser necrosis and perforation. The stomach can undergo volvulus sac, or an occult mass not related to either in the organo-axial (along the long axis of the organ) or trauma. However, in the presence of congenital anomalies the mesentero-axial predisposition.7 Organo-axial volvulus is less 344 Tropical Gastroenterology 2010;31(4):341–344 common in children and is often seen in association with other ground aspirate made us to think in terms of gastric volvulus. predisposing anomalies like eventration, , Pancreatitis was diagnosed per-operatively though the serum hiatus hernia, asplenia, lack of ligaments etc.8 In eventration, amylase was mildly elevated as it nonspecific and elevation depending on the severity of laxity of diaphragm, the occurs in any and it is rare combination of abdominal viscera are under chronic stretch that starts in the simultaneous occurrence. intrauterine period. The negative intra-thoracic pressure during each inspiration applies pull on the abdominal viscera and M. RAGAVAN compression on the thoracic viscera. This chronic stretch leads abnormal lengthening of the ligaments that keeps the internal Correspondence: Dr. M. Ragavan organs fixed to the parietis. Simultaneously this undue stretch Department of Pediatric Surgery not only changes the anatomical position and makes them more Narayana Medical College Hospital prone to volvulus, torsion or trauma but also induces few Chintareddy palem, Nellore – 524002, India. physiological changes that make the organ more susceptible Email: [email protected] to described disease like pancreatitis as in CDH.9,10 Organo- axial volvulus is the commoner and often associated with para- References oesophageal hiatus hernia. In patients with eventration of the diaphragm, the colon rise upwards and twist the stomach by 1. Lynch JM, Adkins JC, Wiener ES. Incarcerated congenital pulling on the gastrocolic ligament and causes an organo-axial diaphragmatic hernia with (Bochdalek). J volvulus.11 However, in our case the stomach was twisted about Pediatr Surg.1982;7:537–40. the long axis of the gastrohepatic ligament and doubled up on 2. Gurses N. Perforating appendicitis within a diaphragmatic hernia: itself causing a mesentero-axial volvulus. This event was a case report. Z Kinderchir. 1986;41:306–7. probably facilitated by the heavy meal the patient had taken 3. Thorp J. Late return of function after intrathoracic torsion of the before the onset of symptoms or dilatation of stomach caused spleen in congenital diaphragmatic hernia. J Pediatr by pancreatitis. It has been suggested that a large intake of Surg.1986;21:722–4. food causes gastric dilatation and approximation of the pylorus 4. Cole BC Dickinson SJ. Acute volvulus of the stomach in infants and cardia which promotes mesentero-axial volvulus11 and is and children. Surgery. 1971;70:707–17. supported by ultrasonographic evidence of fluid and food filled 5. Scherer LR. Volvulus of stomach. In: O2 Neill JA, Rowe MI, dilated stomach in our case. The pathophysiology in our case Grosfeld JL, Fonkalsrud EW, Coran AG, editors. Pediatric can be hypothesized by laxity of all 4 gastric ligaments surgery, 5 th ed. Mosby;1998. p.1127–9. predisposed pancreas for directly brunt. The trauma would 6. Sharma BC, Kapalanga NJB, Ahmed SR. Volvulus of the stomach have induced pancreatitis in an already compromised organ a case report. S Air Med J. 1985;68:48–9 due to chronic stretch. The free fluid of pancreatitis with 7. Darani A, Mendoza-Sagaon M, Reinberg O. Gastric volvulus in irritants and enzymes in the lesser sac would have induced children. J Pediatr Surg. 2005;40:855–58. abnormal gastric dilatation and twisting in a highly mobile 8. Spector JM, Chappell J. Gastric volvulus associated with stomach due to eventration and lax gastric ligaments. Due to wandering spleen in a child. J Pediatr Surg. 2000;35:641–42 the pull of eventration and stretching of ligaments the pylorus 9. Cuschieri RJ, Wilson WA. Incarcerated Bochdalek hernia had moved into the region of left chest producing mesenterico- presenting as . Br J Surg. 1981;68: 669. axial gastric volvulus. In corollary the lax ligaments causing 10. Oliver MJ, Wilson AR, Kapila L. Acute pancreatitis and gastric stretch of organs and gastric volvulus leading to volvulus occurring in a congenital diaphragmatic hernia. J Pediatr pyloroduodenal obstruction causing pancreatitis can be an Surg. 1990;25:1240–41. explanation based on the literature description of acute 11. Tanner NC. Chronic and recurrent volvulus of the stomach with pancreatitis and gastric volvulus occurring in CDH.10 the late results of ‘colonic displacement’. Am J Surg. Eventration of diaphragm in a child with soft consistency 1968;115:505–15. epigastric lump, difficulty in passing nasogastric tube and coffee