Pediatr Surg Int (2001) 17: 596600

Springer-Verlag 2001

ORIGINAL ARTICLE

Essam A. Elhalaby Emad M. Mashaly

Infants with radiologic diagnosis of gastric volvulus: are they over-treated?

Accepted: 6 November 2000

Abstract Gastric volvulus (GV) is a rare condition in infants. The aim of this study was to dene the management strategies of infants with GV based on their clinical and radiologic features. The medical records of 13 infants with a radiologically conrmed diagnosis of GV were retrospectively reviewed. Patients were divided into two groups according to the type of treatment (surgical vs conservative). Abdominal radiographs and upper gastrointestinal contrast studies allowed an unequivocal diagnosis in both groups. Group 1 included 3 infants with acute GV and 2 with chronic, intermittent secondary GV. Three patients had associated diaphragmatic defects, 1 had an ileocolic intussusception, and 1 had hypertrophic pyloric stenosis. The main presenting symptoms were vomiting, dehydration, respiratory distress, and abdominal pain and distention in acute cases and vomiting and failure to thrive in chronic cases. A laparotomy was required in all 5 infants with no recurrence of symptoms. Group 2 included 8 infants with idiopathic chronic GV, who were managed nonoperatively with gradual improvement of symptoms over 12 months. Based on our study, we conclude that: (1) laparotomy can be reserved for patients with either acute or chronic secondary GV; (2) conservative treatment is both safe and eective in infants with chronic idiopathic GV; and (3) routine gastropexy for all patients with a radiologic diagnosis of GV appears to be overtreatment.

Keywords Gastric volvulus Eventration of diaphragm Hiatus hernia

Introduction
Acute gastric volvulus (GV) is a life-threatening, welldened condition that mandates emergency surgical treatment following appropriate resuscitation [13]. Diagnostic delays may result in gastric ischemia, perforation, and even death [4]. In contrast, the proper management of chronic intermittent cases is still controversial [5]. The purpose of this study was to dene the patient characteristics and management strategies of infants with GV.

Materials and methods

Between November 1993 and December 1999, 12 infants with GV were treated in the Department of Pediatric Surgery, Tanta University Hospital, Tiba Charity Hospital, Egypt. Another infant was treated at the C.S. Mott Children's Hospital, University of Michigan Ann Arbor. The medical records of the 13 infants were reviewed with respect to gender, age at diagnosis, presenting symptoms, associated anomalies, roentogenographic studies, treatment and outcome. Patients were divided into two groups according to type of management: group 1 included 5 infants, 3 who presented with acute secondary GV and 2 with chronic intermittent GV secondary to an associated paraesophageal hiatus hernia and hypertrophic pyloric stenosis respectively. A laparotomy was necessary for both gastropexy and treatment of the associated anomalies. Group 2 included 8 infants with idiopathic chronic intermittent GV, who were treated conservatively by maintaining them in a prone position, particularly after feeding, and the use of prokinetic medications. Follow-up ranged from 6 to 84 months. Group 1 Case 1 A 4-month-old boy with a known eventration of the left hemidiaphragm and congenital scoliosis presented with an acute onset of

Presented at the 47th Annual International Congress of the British Association of Pediatric Surgeons, Sorrento, Italy, 1821 July 2000. E. A. Elhalaby (&) Department of Pediatric Surgery, Faculty of Medicine, Tanta University, Tanta, Egypt E. M. Mashaly Department of Radiology, Faculty of Medicine, Tanta University, Tanta, Egypt E. A. Elhalaby Department of Pediatric Surgery, Borg Elmahata, Midan Elmahata, Tanta, 31111, Egypt

597 Fig. 1 Acute mesentericoaxial volvulus: stomach inverted, pylorus (P) obstructed (straight arrow), pointing downward, and at higher level than gastroesophageal junction (curved arrow) and fundus (F) Fig. 2 Acute organoaxial volvulus: hugely distended stomach with single, long air-uid level (arrow)

vomiting, abdominal distention, respiratory distress, and dehydration. The initial diagnostic impression was acute GV. A nasogastric (NG) tube was successfully inserted. An upper gastrointestinal (GI) contrast study showed a mesentericoaxial GV (Fig. 1). A decient gastrosplenic and gastrophrenic ligamentous attachment was noted at laparotomy. Detorsion was easily done, followed by anterior gastropexy and plication of the left hemidiaphragm. The postoperative course was uncomplicated with no recurrence in the 7-year follow-up period. Case 2 A 5-month-old girl presented with a 2-day history of abdominal distention, vomiting, and respiratory distress. An erect abdominal X-ray lm revealed eventration of the left hemidiaphragm and a long, single air-uid level at the upper abdomen (Fig. 2) consistent with an acute GV. An attempt to insert a NG tube was unsuccessful. An urgent laparotomy conrmed the diagnosis of acute organoaxial volvulus. Needle aspiration was required to decompress the twisted stomach. The gastrosplenic, gastrocolic, and gastrophrenic ligamentous attachments were absent. The volvulus was untwisted and a formal anterior gastropexy and plication of the eventrated diaphragm were performed. Recovery was uneventful and no recurrence of symptoms had occurred 6 years postoperatively. Case 3 A 6-month-old boy presented with abdominal pain, vomiting, and an abdominal mass. A water-soluble contrast enema revealed an ileocolic intussusception, which was reduced by hydrostatic pressure. The picture of intestinal obstruction persisted following reduction. An upper Gl series to rule out incomplete reduction of the intussusception incidentally showed a classic picture of organoaxialgastric volvulus (Fig. 3). Abdominal exploration revealed a dilated stomach and small intestine with a non-viable ileo-ileal intussusception. Resection of the non-viable bowel and an ileo-ileal anastomosis was done. There were normal ligamentous and peri-

toneal attachments of the stomach, which was not in a state of volvulus at the time of operation. Preoperative spontaneous detorsion of the volvulus probably occurred following NG tube insertion. A formal gastropexy was not performed because the gastric ligamentous attachments were normal apart from the transient stretching eect of the dilated stomach. Recovery was uncomplicated, and no recurrence occurred in the 4-year follow-up period. Case 4 A 5-month-old girl presented with a 3-week history of recurrent hematemesis, vomiting, and tachypnea. A plain chest X-ray lm showed a right paracardiac opacity. An upper GI contrast study showed an organoaxially-rotated stomach in the chest (Fig. 4). The volvulus was untwisted; the herniated stomach was reduced and xed to the anterior abdominal wall, followed by repair of the hiatus hernia through an abdominal approach. Case 5 A 2.5-month-old girl presented with recurrent non-bile-stained vomiting, constipation, and failure to thrive. An upper GI contrast study showed an organoaxially-rotated stomach with delayed emptying of contrast. At laparotomy the stomach was not in a state of volvulus, but was hugely distended with signicant laxity of the gastrocolic ligament. An associated hypertrophic pyloric mass was noted. Pyloromyotomy and anterior gastropexy were performed, with no recurrence of symptoms on follow-up of 48 months. Group 2 None of the 8 infants (5 boys and 3 girls aged 3 to 8 months, mean 5.6 months) had an associated diaphragmatic defect or predisposing cause apart from possible laxity of the ligamentous attachments. The main symptoms were recurrent abdominal pain

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Fig. 3 Acute organoaxial volvulus with partial gastric outlet obstruction: stomach horizontal with greater curvature (arrowhead) higher than lesser curvature. Pylorus (P) obstructed (arrow) and nearly level with fundus (F) Fig. 4 Right paraesophageal hiatus hernia with chronic intermittent organoaxial volvulus. (GC greater curvature) Fig. 5 Chronic idiopathic organoaxial volvulus: horizontal stomach with fundus (F) lower than greater curvature (GC). Non-obstructed pylorus (P) points downward Fig. 6 Chronic idiopathic organoaxial GV gastric volvulus (P pylorus, F fundus)

and vomiting, abdominal distention, and failure to thrive. All patients had well-documented radiologic features of chronic idiopathic GV (Figs. 5 and Fig. 6). Six patients had organoaxial and 2 had combined organoaxial and mesentericoaxial GV. Three infants had associated gastroesophageal reux with recurrent episodes of chest infection, probably due to aspiration. The number of hospitalizations ranged from one to four, and the mean hospital stay was 5 days. All 8 patients were managed conservatively, with gradual improvement of their symptoms over a 12-month period.

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Results
There was no mortality in this series. Follow-up ranged from 6 to 84 months. All patients in group 1 exhibited immediate improvement of their GI symptoms following surgery, while clinical improvement was gradual in group 2. The mean hospital stay directly related to the volvulus was comparable in both groups (6 and 5 days, respectively). Growth curves were higher for the surgically-treated group initially, but curves were comparable a few months later. No conversion to acute GV occurred in any patient from group 2.

Discussion
Gastric volvulus has been broadly dened as an abnormal degree of rotation of one part of the stomach around another [6]. Abnormalities of gastric xation represent a spectrum ranging from nearly complete absence of the ligamentous attachments of the stomach, which occurs in some cases of congenital diaphragmatic defects, to mere laxity of such attachments. Likewise, the degree of GV ranges from acute complete volvulus to recurrent episodes of incomplete torsion. The rotation may occur around a line joining the hiatus and pylorus in cases of organoaxial volvulus, or around a line joining the greater and lesser curvatures in mesentericoaxial volvulus. Rarely, a mixed volvulus occurs due to biplane rotation. The clinical symptoms of infants with GV depend on the degrees of rotation and obstruction [1, 7]. Our study and several others [1, 7, 8] have shown that the classic Borchardt's triad (unproductive retching, acute localized epigastric distention, and inability to pass a NG tube), which was described in adults, is not reliable in the pediatric population [9]. Insertion of a NG tube was possible in all our patients except 1, and non-bilious vomitus was a salient feature. Likewise, the pentalogy of clinical manifestations (intermittent colicky abdominal pain, non-bilious vomiting, upper abdominal distension, failure to thrive, and hematemesis) described by Samuel et al. [8], are not specic enough to make a diagnosis of GV in infants on clinical grounds only. In contrast to the nonspecic clinical symptoms, the radiologic features are usually characteristic [1, 7]. In mesentericoaxial GV, with the stomach lying vertically upside down, the pylorus is higher than the esophagogastric junction (EGJ). Double air-uid levels, one at the body and the other at the pyloric canal, are evident on an erect plain abdominal radiograph. In organoaxial volvulus, the stomach is lying horizontally with the greater curvature at a higher level than the lesser curvature, the pyloric canal crosses the distal esophagus, and the pylorus usually points downward and at nearly the level of the EGJ. A single, long air-uid level is usually noted on an erect plain lm when the volvulus is complete.

GV may be idiopathic or secondary to other anatomic anomalies associated with decient ligamentous attachment of the stomach such as diaphragmatic defects [1012], asplenia [13], wandering spleen [14], and malrotation of the gut [8]. Five cases in our series (group 1) as well as most of the published cases of GV in infants were of the secondary type [1, 4, 7]. The diagnosis of acute GV should be considered in any infant with acute GI obstruction coexisting with a diaphragmatic defect. Radiologic assessment should be done urgently to rule out this possibility. Maintaining a high index of suspicion enabled us to correctly diagnose acute GV in 2 of our 3 cases even before any radiologic studies. Surgical treatment for secondary GV, whether acute or chronic, is universally accepted. Emergency or elective surgery will be dictated by the degree of obstruction. Following detorsion of the malrotated stomach, a diaphragmatic defect is repaired if present. The stomach is then xed to avoid the recurrence of volvulus. Gastropexy can be accomplished by xation of the stomach to the anterior abdominal wall by either a few interrupted sutures or by a gastrostomy. Recently, successful laparoscopic gastropexy has been reported in children with acute GV [3]. Approximately one-third of patients with GV have no associated abnormalities, and this is known as the primary or idiopathic type [6]. Although idiopathic GV is considered a distinct entity that occurs more frequently than generally reported [15, 16], its existence is considered debatable by some due to the unclear distinction from ``oppy stomach,'' which is a radiologic nding with little clinical signicance [2]. Eight of our patients (group 2) had chronic idiopathic GV, and all of them had classic radiologic features of GV (Figs. 5 and 6) rather than simply a ``oppy stomach.'' The key feature of ``oppy stomach'' is the disappearance of the radiologic manifestations of torsion with a change of the patient's position during the upper GI contrast study. In contrast, the radiologic features of infants with either GV or torsion persist in dierent positions. In acute GV, there is complete obstruction at either the EGJ or gastroduodenal junction or both. In chronic GV or torsion, there is a varying degree of partial obstruction at the gastric inlet and outlet. We believe that the term chronic GV should be considered synonymous with gastric torsion. Cole and Dickinson [7] restricted the term volvulus to instances with complete obstruction of the lumen, and suggested torsion as an alternative term in the absence of such obstruction. The treatment of chronic idiopathic GV or torsion remains controversial. Successful conservative management was reported in two large series of infants below 6 and 12 months of age with GV [15,16]. Positioning of the infant in the prone or upright position for at least 1 h after meals was advocated to prevent possible posterocaudal rotation of the dilated gastric fundus, which is lled with milk in the supine position [15]. The same positional therapy was used successfully in conjunction

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with prokinetic drugs in 8 of our patients (group 2). Gradual improvement of tone and strength of the gastric ligamentous attachments may explain the cessation of recurrent episodes of volvulus and justify this conservative approach. Although our study was not randomized, it provides a strong clinical evidence that chronic, intermittent primary GV responds well to expectant therapy. While gastropexy is indicated in cases refractory to conservative treatment [17], its routine use in each case with radiologic features of GV would appear to be overtreatment.
Acknowledgements The authors thank Dr. Arnold G. Coran, Chief of Pediatric Surgery, University of Michigan, for permission to include a patient from his institution in this study, and Dr. Amel Hashish for her assistance in preparing the manuscript.

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