Gastric Volvulus Revealed by Peritoneal Syndrome

www.kosmospublishers.com [email protected] DOI: 10.37722/JSOTA.2020101

Case Report Journal of Surgery, Operative Techniques and Anesthesia JSOPA-114 ISSN: 2688 -0873

Case Report: Gastric Volvulus Revealed by Peritoneal Syndrome

H. Elloumi*, H. Harbi, MT. Frikha, R. Mzali

Visceral and digestive surgery department, Habib Bourguiba Hospital, Sfax, Rue Al Firdaws, 3029, Tunisia

Received Date: April 10, 2021; Accepted Date: May 10, 2021; Published Date: May 20, 2021

*Corresponding author: H.Elloumi, Visceral and digestive surgery department, Habib Bourguiba Hospital, Sfax, Rue Al Firdaws, 3029, Tunisia. Email: [email protected]

Abstract Observation

Acute gastric volvulus is a diagnostic and a therapeutic This is a 43-year-old female patient with a medical history emergency; it can be complicated by peritonitis and of adrenal insufficiency and treated hypothyroidism. She gastrointestinal bleeding. 43-year-old Mrs. R.M is reported presented multiple episodes of vomiting progressing by with a history of adrenal insufficiency and hypothyroidism, seizures and giving way spontaneously for a year. She has who consults for sudden abdominal pain as well as been presenting for 3 days for epigastric pain associated with unproductive vomiting. The examination notes abdominal nausea and not giving way to medical treatment. Faced with distension and polypnea, the biology marks a SIB and acute the worsening and generalization of pain throughout the renal failure. The computed tomography examination reveals a abdomen, she went to the emergency room. large abundance of pneumoperitoneum and partial gastric pneumatosis. The patient was operated on for peritonitis Clinical examination of the patient found blood pressure at related to gastric perforation resulting from a complete 90/60 mm Hg, pulse at 110 bpm, polypnea at 32 C / min, and mesenteric-axial volvulus of the stomach; we also note the generalized abdominal distension with defense of the left presence of a wandering spleen during exploration. The hypochondrium. A Biologically, she had a hyperleukocytosis patient underwent mechanical resection of the necrotic at 18,000 elements / mm3, an elevated CPR at 380 mg /l and peripheral portion of the stomach. The course was marked by acute renal failure (renal clearance at 25 ml / min). the onset of septic shock, acute adrenal insufficiency and the death of the patient on D-3 postoperatively. The patient was admitted to a surgical intensive care unit. She had monitoring measures, crystalloid filling, ventilation Keywords: Gastric perforation; Gastric volvulus, management; with a mask, a nasogastric tube which brings back a bilious mesenteric-axial fluid and a preparation for the realization of an emergency surgical treatment… Introduction An unprepared x-ray of the abdomen showed gastric gas Gastric volvulus is a rare condition, the incidence of which distension and parietal emphysema of the stomach (Figure 1). is difficult to estimate. In 5% of cases this pathology is revealed by a complication [1]. In acute and complicated forms, diagnosis and treatment should be carried out urgently [2, 3]. The clinical and therapeutic peculiarities of a case of gastric volvulus revealed by acute peritonitis are reported.

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Case Report: Gastric Volvulus Revealed by Peritoneal Copyright: © * Syndrome 2020 H. Elloumi

Figure 3: Axial section of an abdominal CT scan showing parietal emphysema in the volvulated portion of the stomach (black arrow).

Figure 1: Abdomen without preparation revealing pneumoperitoneum (black arrow) and thickening of the gastric wall (white arrow).

The abdominal CT scan found fluid effusion and extensive pneumoperitoneum as well as partial gastric pneumatosis (Figures 2, 3 and 4).

Figure 4: Coronal slice of an abdominal CT scan showing the site of the stomach volvulus (blue arrow), parietal pneumatosis (white arrow).

Figure 2: Frontal section of a thoraco-abdominal CT scan In addition, the proximal gastric portion (orange arrow) is showing an ectopic position of the spleen tilted down (black healthy and the spleen is in an ectopic position (black arrow). arrow). After a brief resuscitation, the patient was operated on by

the midline. There was generalized purulent peritonitis and complete mesenteric-axial stomach volvulus resulting in peripheral gastric necrosis that follows all around the greater curvature and part of the fundus. In addition, there was a 2 cm posterior perforation of the necrotic portion. The spleen was very mobile (wandering spleen) with hyperlaxity of the gastro- splenic and gastro-phrenic ligaments (Figures 5 and 6) with

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Case Report: Gastric Volvulus Revealed by Peritoneal Copyright: © * Syndrome 2020 H. Elloumi

the possibility of easily lowering the cardia more than 10 cm [1, 7]. In the literature, there is no gender predilection [2, 4] from the esophageal hiatus. although some authors believe that there is a female predominance [3, 8]. Several etiologies of LV have been suggested: diaphragmatic hernias are the most frequent cause [2, 9]. "Wandering spleen" or "beating of the bell" spleen can also be another common cause of LV. Indeed, the absence of the gastro-splenic ligament and the posterior fixation of the meso of the spleen tilts the great curvature and the posterior face of the stomach forward as was the case of our patient [10- 12]. We also cite liver abnormalities and gastric tumors [9, 13]. Ligament hyperlaxity is a constant and essential element favoring the occurrence of LV. It causes the posterior surface of the stomach to tilt forward, starting the first stage of a volvulus. It can be congenital or acquired (eg due to pregnancy, obesity, dehydration or muscle atrophy) [10, 16- 18]. There are four types of LV : organo-axial rotations (along a cardio-pyloric axis) which are the most frequent (> 60%), mesenteric-axial rotations (along a medio-gastric transverse axis passing through the small and the large curvatures) which are seen in 29% of cases, combined or mixed rotations (10%) Figure 5: Intraoperative appearance of gastric necrosis. and the so-called unclassifiable type (2%) [14]. Organoaxial type volvuli are often described in hiatus hernias and antrum tumors [14, 15].

LV is said to be complete when the angle of rotation of the stomach is between 180 ° and 360 ° with gastric obstruction and strangulation. LV is said to be incomplete when the rotation is less than 180 ° [14]. LV can present in an acute, subacute or chronic clinical form: in the chronic form, the symptoms are not very specific, not very noisy with an evolution by crises giving way spontaneously and suddenly [21]. The subacute form is the prerogative of mesenteric-axial forms such as our case with signs related to gastric emptying disorders [21]. The acute form is characterized by the classic Borchart triad associating acute epigastric pain. (And / or left hypochondrium), abdominal distension and nausea [1]. In the absence of this triad, the acute form can be revealed by a complication,

namely mainly a high digestive stenosis of sudden installation, Figure 6: Intraoperative appearance of gastric perforation. a gastric perforation (secondary to gastric strangulation and at the origin of peritonitis) or a hemorrhage upper digestive The patient underwent peritoneal toilet and longitudinal system [1, 19, 21]. Other complications of LV can be gastrectomy removing the entire necrotic portion of the mediastinitis, cardiac arrhythmias, tamponade, and respiratory stomach. This was achieved by linear stapling forceps as in the distress [1]. case of a sleeve gastrectomy. The remaining stomach was relatively large and not tubular. The postoperative course was Our observation is a case of acute gastric volvulus with a marked by the onset of acute adrenal insufficiency and a state history of subacute attacks, associated with ligament hyperlaxity of septic shock leading to the death of the patient on D-3 and a wandering spleen, who consults for a Borchart triad and postoperatively. peritoneal syndrome evolving for three days. X-ray of the abdomen without preparation is generally not helpful but can Discussion sometimes show gas distension of the upper abdomen or parietal emphysema [20], as was the case in our observation.

Thoraco-abdominal computed tomography is the gold Gastric volvulus is defined by an abnormal rotation of all standard: it makes it possible to make a positive diagnosis of or part of the stomach with respect to one of its axes causing LV, to specify the type of rotation and to look for a possible upper digestive stenosis with the risk of strangulation [4, 5]. complication, mainly gastric parietal necrosis (and / or This is a rare condition given the stomach's ability to fixate vascular suffering). It also makes it possible to highlight an [6]. It is usually seen in people in their 50s [4, 5], although associated gastric tumor or a wandering spleen [6]. LV is a cases have been reported in younger subjects like our patient 3 | Journal of Surgery, Operative Techniques and Anesthesia, Volume 2020, Issue 01

surgical emergency because it requires rapid stomach 9. Cameron AE, Howard ER (1987) Gastric volvulus in distortion and gastropexy [6, 22]. This can be done by childhood. J Pediatr Surg 22: 944-947. laparotomy or by laparoscopy [3, 6, 22, 23] knowing that the 10. Benoit L, Goudet P, Cougard P (1997) Acute laparoscopic technique offers the classic advantages of a intraabdominal gastric volvulus in adults. Defect of dorsal shorter hospital stay and less morbidity [22-24]. The causes of mesogastrium fusion. Ann Chir 51: 379-381. conversion (10%) are dominated by the presence of ischemia 11. Aliye U, Simon C, Kao D, Kathleen D, Lawrence J and the difficulty of exposure [3, 25, 26]. The treatment in (1998) Gastric volvulus and wandering spleen. Am J case of necrosis or perforation consists in performing a Gastroenterol 93: 1146-1148. gastrectomy, which is exceptionally complete [2] as we did in 12. Qazi A, Awadallah S (2004) Wandering spleen: a rare our patient who had a longitudinal gastrectomy removing the cause of mesenteroaxial gastric volvulus. Pediatr Surg Int necrotic part. 20: 878-880. 13. Larricq J (1998) Pathologie gastrique rare. EMC The postoperative morbidity and mortality of acute forms Gastroente´ rologie 9-031-B-10: 1-3. of LV is relatively high: the morbidity exceeds 66% and is 14. Shivanand G, Seema S, Srivastava DN, Pande GK, Sahni favored by the oragano-axial type of rotation, complete P, et al. (2003) Gastric volvulus Acute and chronic obstruction and the presence of cardio-respiratory defects [3, presentation. Clinical Imaging 27: 265-268. 26, 27]. Mortality rises to more than 50%. The factors of poor 15. Chafke N, Wihlm JM, Massard G, Morand G, Witz JP prognosis are advanced age, the presence of comorbidities, the (1988) La hernie retro-costo-xiphoïdienne. Proble` mes de urgency of the surgery, the presence of necrosis requiring diagnostic et de traitement. A propos de huit observations. gastric resection and the delay in diagnosis and treatment [28 - Ann Chir 42: 467-473. 30]. Our patient was young, but had all the other criteria for a 16. Honna T, Kamii Y, Tsuchida Y (1990) Idiopathic gastric poor prognosis. volvulus in infancy and chilhood. J Pediatr Surg 25: 707- 710. Conclusion 17. Arimont JM, Ramoisiaux L, Majerus B (1998) Cure laparoscopique d’une hernie rétro-costoxyphoidienne LV remains a rare cause of gastric perforation. This is a compliquée d’une occlusion par volvulus gastrique surgical emergency requiring partial or total gastric resection intrathoracique. Ann Chir 52: 660-664. depending on the extent of the necrosis. Improved prognosis 18. Smith J, Ghani A (1995) Morgani hernia:incidental repair depends on early diagnosis and treatment of chronic and sub- during laparoscopic cholecystectomy. J Laparoendosc acute forms. Surg 5: 123-125. 19. Uc A, Kao SC, Sanders KD, Lawrence J (1998) Gastric References volvulus and wandering spleen. Am J Gastroenterol 93: 1146-1148. 1. Carter R, Brewer LA, Hinshaw DB (1980) Acute gastric 20. Gonzalez JJ, Alvarez PJA (1991) Volvulus gastrique. volvulus. A study of 25 cases. Am J Surg 1980 140: 90- EMC Gastroenterologie 9-031-B-12. 106. 21. Bedioui H, Bensafta Z (2008) Volvulus gastrique : 2. Menguy R (1995) Le traitement chirurgical des hernies diagnostic et prise en charge thérapeutique. Presse Med hiatales par roulement avec volvulus intrathoracique de la 37: e67–e76. totalite´ de l’estomac. Chirurgie 120: 439-443. 22. Rantomalala HY, Rajaonarivony T, Rakototiana AF, 3. Alamowitch B, Christophe M, Bourbon M, Porcheron J, Balique JG (1999) Hernie hiatale paraoesophagienne avec Rakotoarisoa AJ, Ramarosandratana JL, Razakatiana L, et volvulus gastrique aigue¨. Gastroenterol Clin Biol 23: al. (2005) Un cas de volvulus aigu de l?estomac chez 271-274. l?enfant . Archives de pédiatrie 12: 1726-28. 4. Bedioui H, Bensafta Z (2008) Volvulus gastrique: 23. Herinirina SAE, Rasataharifetra H, Rasamoelina diagnostic et prise en charge thérapeutique. Presse Med. Rakotoarijaona AH, Ratsivalaka R (2010) Un cas de 37: e67-e76. volvulus gastrique aigu de l’adulte au Centre Hospitalier 5. Hillemand P, Bernard HJ, Villard J (1955) A propos des volvulus gastriques.Sem HopParis 31: 2890-2899. Universitaire de Toamasina. Revue Tropicale de 6. Grignon B, Sebbag H, Reibel N, Zhu X, Grosdidier G, et Chirurgie 4: 22- 23. al. (2004) Diagnostic tomodensitométrique d’un volvulus. 24. Miller DL, Pasquale MD, Seneca RP, Hodin E (1991) 85: 1070-1073. Gastric volvulus in the pediatric population. Arch Surg 9: 7. Godshall D, Mossallam U, Rosenbaum R (1999) Gastric 1146-1149. volvulus: Case report and review of literature. J Emerg 25. Kuwano H, Hachizume M, Sumiyoshi K, Sugimachi K, Med 17:837-840. Haraguchi Y (1998) Laparoscopic repair of a 8. Cloyd DW (1994) Laparoscopic repair of incarcerated paraoesophageal hernia. Surg Endosc 8: 893-897. paraoesophageal hiatal hernia with gastric volvulus. Hepatogastroenterology 45: 303-306.

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26. Alamowitch B, Boubon M, Porcheron J, Pyneeandee S, 28. Leblanc I, Scotte M, Michot F, Teniere P (1991) Incarce´ Balique JG (1995) Volvulus gastrique aigue¨ sur hernie ration gastrique sur hernies hiatales para-oesophagiennes hiatale revelee par une lithiase chole´ docienne. J Chir et par glissement.Ann Chir 1991;45:42-5. (Paris) 132: 454-458. 29. Haas O, Rat P, Christophe M, Friedman S, Favre JP 27. Christophe M, Rat P, Sala JJ, Dia A, Favre JP (1989) Le (1990) Surgical results of intrathoracic gastric volvulus volvulus intrathoracique de l’estomac dans les hernies complicating hiatal hernia.Br J Surg 77: 1379-1381. 30. Harriss DR, Graham TR, Galea M, Salama FD (1992) hiatales. Sem Hop Paris 65: 2583-2587. Paraoesophageal hernia: when to operate? JR Coll Surg Edinb 37: 97-98.

Citation: Elloumi H, Frikha MT, Mzali R (2021) Case Report: Gastric Volvulus Revealed By Peritoneal Syndrome. Jr Surg Opetech Anesthesia: JSOPA-114.

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