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Acute Gastric Volvulus and Pancreatitis Following Abdominal Trauma in A Tropical Gastroenterology 2010;31(4):341–344 neurological disorders will require a feeding jejunostomy. In Acute gastric volvulus and advanced cases surgery remains the only option with resection of the necrosed segment and reconstruction by anastomosing pancreatitis following abdominal the esophageal end to the remaining stomach or the jejunum. 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 gastric volvulus 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 vomiting. References Abdominal distension was confined to upper abdomen. There was history of constipation for 4 days. There was no history of 1. Todd SR, Marshall GT, Tyroch AH. Acute gastric dilatation fever 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 complication 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 pneumoperitoneum. All these suggested left sided eventration lying low and anterior to pylorus 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 gangrene 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 radiography 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 hernia (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 appendicitis 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 signs and symptoms such as abdominal Discussion distension, vomiting, pain, and retching. 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
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