ILLUSTRATIVE CASE
Acute Gastric Volvulus in a 16-Year-Old Male Adolescent A Case Report Dimas C. Espinola, MD, MPS,* Sharif R. Nankoe, MD,† and Pegeen W. Eslami, MD† Objective: We described a case of acute mesenteroaxial gastric volvulus in a male adolescent who presented to the pediatric emergency department (ED). Case: A previously healthy male adolescent presented to the pediatric ED with gradual onset of epigastric pain, emesis, and a soft and nondistended abdomen. After evaluation, management, and resolution of the pain, the patient was discharged home with a primary care follow-up plan. Approximately 5 hours after discharge, the patient returned to the pediatric ED with worsening abdominal pain, the inability to tolerate oral intake, and a firm and distended abdomen. Subsequent evaluation identified an acute mesenteroaxial gastric volvulus. Pediatric surgeons performed an exploratory laparotomy, reduction of the gastric volvulus, and gastropexy, and the patient was discharged after a brief hospitalization. Conclusions: Acute gastric volvulus can present with symptoms similar to benign abdominal etiologies. Timely diagnosis and intervention are key to improved outcomes for patients. Key Words: gastric volvulus, surgery, adolescent, emesis (Pediatr Emer Care 2015;00: 00–00)
irst described in the pediatric population by Oltman in 1899,1 gastric volvulus is not a common diagnosis in this population. A total of 581 cases of pediatric gastric volvulus have been reported in the literature between 1929 and 2007. Of these cases, only 252 were an acute presentation.2 This uncommon diagnosis can be easily overlooked given its similar initial presentation to more common etiologies of pediatric abdominal pain. It is important to keep gastric volvulus in mind when evaluating patients with similar presentations or patients whose complaints do not resolve with the usual therapies, because the sequelae of the missed diagnosis can result in potentially life-threatening events for the patient. Here, we outline a case of a male adolescent who presented to the pediatric emergency department (ED) with vomiting and subsequently whose condition was diagnosed as acute mesenteroaxial gastric volvulus.
F
CASE A Somali-born male adolescent was brought into a tertiary care pediatric ED by his father with a complaint of acute onset of epigastric pain and several episodes of nonbilious, nonbloody emesis because the pain started approximately 5 hours earlier. The patient had a history of mild developmental delay. The patient and his father denied any other medical history or surgical history. The adolescent immigrated to the United States in 2005 with no recent travel outside the country. The patient’s only medication was guanfacine for behavioral issues, and he had no reported allergies. From the *Department of Pediatrics, Walter Reed National Military Medical Center, Bethesda, MD; and †Department of Pediatric Emergency Medicine, UMass Memorial Medical Center, Worcester, MA. Disclosure: The authors declare no conflict of interest. Reprints: Dimas C Espinola, MD, MPS, Department of Pediatrics, Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD 20889 (e‐mail: [email protected]). Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0749-5161
Pediatric Emergency Care • Volume 00, Number 00, Month 2015
On physical examination, his vital signs were stable and his abdomen was soft, not notably distended, and diffusely tender to palpation in the upper quadrants without rebound or guarding. The patient received intravenous fluids, analgesia, and antiemetics. Basic blood work, including a liver profile and a lipase, was unremarkable. An upright abdominal radiograph was ordered, and it showed marked gastric distention with question of recent fluid ingestion but no evidence of small or large bowel obstruction (Fig. 1). After 6 hours of observation, the patient felt better. His abdomen remained soft and nondistended, and the abdominal tenderness, which was attributed to multiple episodes of vomiting, had resolved. The patient had no additional episodes of emesis, and he tolerated oral fluids. The patient was discharged with planned follow-up within 24 hours with his primary care physician. Approximately 5 hours after discharge, the patient again presented with his father to the ED with worsening abdominal pain. The patient described a diffuse burning pain in his upper abdomen, and he was unable to keep food or fluids down because of it. The family stated that the symptoms had started again shortly after discharge earlier that day. Since his discharge, they reported 5 episodes of nonbilious, nonbloody emesis. On physical examination, his vital signs were stable, but his abdomen was firm, obviously distended, and diffusely tender to palpation. Another upright abdominal radiograph showed further distension, with more air in the stomach and less distal gas in the intestine when compared with the previous radiograph (Fig. 2). The finding raised concern for intrinsic versus extrinsic gastric outlet obstruction. A nasogastric (NG) tube was placed and drained approximately 1200 mL of yellow-green fluid; however, his pain persisted. On a scout abdominal radiograph, the gastric distension was not visibly relieved by the NG tube placement, and the NG tube had entered the stomach more inferiorly and medially than expected (Fig. 3). Pediatric surgery was consulted. An abdominal and pelvic computed tomography (CT) scan was ordered. Coronal and axial images were notable for the NG tube entering at the gastroesophageal (GE) junction, with the GE junction more medially and inferiorly positioned than normal (Fig. 4). In addition, the imaging showed pylorus displacement superior and to the left when compared with the normal pylorus location (Fig. 5). These images confirmed that the stomach was rotated, and pediatric radiology confirmed a diagnosis of mesenteroaxial gastric volvulus. The pediatric surgery service took the patient to the operating room for exploratory laparotomy, reduction of the mesenteroaxial gastric volvulus, and gastropexy. There were no complications during the procedure, and the patient was transferred to the pediatric intensive care unit (PICU) for observation and management. During his PICU course, he received ventilatory support for 24 hours and then was successfully extubated. He was transitioned to oral feeds and did well during his remaining PICU course before being discharged home with an appropriate follow-up course.
DISCUSSION Normally, the stomach is fixed in position by the following 4 ligaments: the gastrocolic, gastrohepatic, gastrophrenic, and gastrosplenic ligaments. Either laxity or absence of these ligaments can lead to primary gastric volvulus, whereas secondary www.pec-online.com
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
1
Pediatric Emergency Care • Volume 00, Number 00, Month 2015
Espinola et al
FIGURE 1. Upright abdominal radiograph from the first ED visit with arrow denoting gastric wall margin.
gastric volvulus is the result of gastric anatomic abnormalities or adjacent organ abnormalities.2,5 Etiologies of secondary gastric volvulus include gastric outlet obstruction, diaphragmatic hernia (congenital or acquired), hiatal hernia (most commonly as paraesophageal hernia), asplenia syndrome or severe chronic
FIGURE 2. Upright abdominal radiograph from the second ED visit with arrow denoting gastric wall margin.
2
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splenomegaly, wandering spleen, intestinal malrotation, and abdominal bands or adhesions.2,4 Gastric volvulus is best described as a twisting of the stomach greater than 180 degrees around either its short axis (transecting the greater and lesser curvatures) or long axis (transecting the pylorus and hiatus of the diaphragm). Mesenteroaxial volvulus occurs when the stomach rotates on its short axis, and organoaxial volvulus occurs when the stomach rotates on its long axis.3 A combined volvulus describes a gastric rotation around both the short and long axes.2 Gastric volvulus can have an acute or a chronic clinical presentation. Acute gastric volvulus typically presents with nonbilious emesis, abdominal pain, and distention and can precipitate respiratory or cardiovascular collapse as a result of increased intrathoracic pressure. Respiratory distress can also result from aspiration pneumonia associated with recurrent emesis.6 The severity of symptoms relates to the degree of rotation, the extent of the resulting gastric obstruction, and whether the stomach can unrotate on its own (intermittent volvulus). A fixed volvulus can result in gastric ischemia, with or without perforation, and with or without possible sepsis. This possibility reinforces the need for quick recognition and surgical intervention in an acute presentation. Mesenteroaxial gastric volvulus carries a higher risk for gastric ischemia due to the anatomy of the rotation in relation to the gastric blood supply.6 Chronic gastric volvulus may present with recurrent abdominal pain, recurrent chest infections, chronic nausea and emesis, and failure to thrive, particularly in younger infants.6 Between 1929 and 2007, only 581 cases of gastric volvulus in the pediatric population are reported in the literature.2 Approximately one fifth of the total reported pediatric gastric volvulus cases are seen in pediatric patients younger than 1 year, and these
FIGURE 3. Scout abdominal radiograph after NG tube placement with arrow denoting the NG tube more inferiorly and medially positioned. © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Pediatric Emergency Care • Volume 00, Number 00, Month 2015
Acute Gastric Volvulus in an Adolescent Male
FIGURE 4. Axial and coronal CT abdomen/pelvis slices identifying the GE junction more medially and inferiorly positioned than normal.
are typically due to congenital diaphragmatic disorders.4 Approximately 80% of cases are reported in patients younger than 5 years.3 Interestingly, less than 5% of pediatric cases occurred in adolescents.2 This age differential could be due to the fact that existing congenital or anatomical defects would tend to predispose to a presentation in a much younger pediatric age group. The fifth decade of life is the peak incidence for gastric volvulus,4 and 30% of these adult patients present with Borchardt’s triad of epigastric distention, an inability to pass the NG tube, and intractable retching.3 Of 252 acute pediatric gastric volvulus cases reported between 1929 and 2007, 54% were organoaxial, 41% were mesenteroaxial, and 2% were combined.2 In addition, the acute cases tended to present earlier in life, with approximately 21% appearing in the first month, 58% appearing in the first 12 months, and 85% by the age of 5 years.2 The reported incidence in adolescents aged 13 to 18 years was only 4%,2 which translates to a total of 10 adolescent patients during this 78-year period of reporting. The treatment and outcome of the acute cases were related, in part, to the frequency of need for acute resuscitation in this group, with surgical repair reported in almost 90% and a mortality rate of less than 7% overall.2 Of the 252 acute presentations, 47 patients (approximately 19%) did have a history suggestive of previous
chronic intermittent volvulus.2 These chronic presentations are associated with spontaneous correction of the gastric volvulus but can transition to an acute gastric volvulus if the orientation of the stomach does not correct itself.5 A slight majority of the reported pediatric cases in the literature (57%) do present as chronic, recurrent, or intermittent with a striking predominance (74%) being of primary etiology. Of 329 chronic clinical presentations, 85% were of the organoaxial type, 10% were mesenteroaxial, and 3% were combined.2 Interestingly, when looking at chronic gastric volvulus, Cribbs et al2 suggest that differing rates of diagnosis and treatment approaches exist when comparing the United States with Africa, Asia, and Europe. The authors suggest that these differences may, in part, be due to the common empiric treatments of gastroesophageal reflux disease in the United States, compared with other countries where the more frequent use of upper gastrointestinal studies may detect the otherwise unsuspected condition of chronic gastric volvulus.2 In our case, the patient presented as a previously healthy, thriving male adolescent with nonbilious vomiting, epigastric pain, and no previous reported episodes of similar symptoms, during a time of the year when many patients were presenting with gastroenteritis. Of note, he described upper abdominal pain, multiple episodes of
FIGURE 5. Axial and coronal CT abdomen/pelvis slices identifying pylorus displacement superiorly and to the left. © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
3
Pediatric Emergency Care • Volume 00, Number 00, Month 2015
Espinola et al
nonbilious and nonbloody emesis over the course of several hours, and the inability to tolerate oral intake but no diarrhea. His initial ED visit seemed unremarkable and consistent with early gastroenteritis, and he was discharged home with instructions for close follow-up after tolerating an oral challenge and feeling better after a few hours. However, his return within a few hours with renewed vomiting and abdominal pain, along with new-onset abdominal firmness and distention raised our suspicions for a more serious etiology. The degree of progressive gastric distension was remarkable. On subsequent review of the initial presentation and radiographs, pediatric radiology commented on the lack of specific findings to suggest the diagnosis of gastric volvulus. On the initial abdominal radiographs (Fig. 1), the stomach size was consistent with a recent fluid ingestion, a hypersecretory state, or a bezoar causing gastric outlet obstruction. Hindsight, in combination with the progression of symptoms, serves to emphasize the importance of a broad differential diagnosis, close patient follow-up after discharge, and clear communication to patients and families regarding concerning signs and symptoms, such as indications for return to the ED. In this case, management included NG tube placement that did not alleviate his symptoms, subsequent additional definitive radiographic imaging that confirmed a mesenteroaxial gastric volvulus, emergent pediatric surgery intervention, and postoperative monitoring before hospital discharge.
CONCLUSIONS While quite uncommon in the pediatric population, gastric volvulus should be considered in the differential diagnosis of
4
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pediatric patients presenting with abdominal pain, emesis, lack of “viral” symptoms, an atypical response to the usually effective symptomatic treatment, and an abnormal abdominal physical examination or unexpected abdominal radiography findings. In such presentations, the case outlined here emphasizes the importance of physical examination changes over time and the importance of additional imaging in these situations. In addition, the question of whether chronic intermittent gastric volvulus is often “missed” in US pediatric patients is provocative; however, the presentation of acute versus chronic gastric volvulus seems to be qualitatively distinct. In particular, accurate diagnosis and timely intervention in acute gastric volvulus are key to improved outcomes for patients. REFERENCES 1. Oltman H. Inaugural Discussion. Kiel. 1899. 2. Cribbs R, Gow K, Wulkan M. Gastric volvulus in infants and children. Pediatrics. 2008;122:e752–e762. 3. Mayo A, Erez I, Lazar L, et al. Volvulus of the stomach in childhood: the spectrum of disease. Pediatr Emerg Care. 2001;17:344–348. 4. Godshall D, Mossallam U, Rosenbaum R. Gastric volvulus: case report and review of the literature. J Emerg Med. 1999;17:837–840. 5. Darani A, Mendoza-Sagaon M, Reinberg O. Gastric volvulus in children. J Pediatr Surg. 2005;40:855–858. 6. Tillman BW, Merritt NH, Emmerton-Coughlin H, et al. Acute gastric volvulus in a six-year-old: a case report and review of the literature. J Emerg Med. 2013;46:191–196.
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Acute Gastric Volvulus in a 16-Year-Old Male Adolescent A Case Report Dimas C. Espinola, MD, MPS,* Sharif R. Nankoe, MD,† and Pegeen W. Eslami, MD† Objective: We described a case of acute mesenteroaxial gastric volvulus in a male adolescent who presented to the pediatric emergency department (ED). Case: A previously healthy male adolescent presented to the pediatric ED with gradual onset of epigastric pain, emesis, and a soft and nondistended abdomen. After evaluation, management, and resolution of the pain, the patient was discharged home with a primary care follow-up plan. Approximately 5 hours after discharge, the patient returned to the pediatric ED with worsening abdominal pain, the inability to tolerate oral intake, and a firm and distended abdomen. Subsequent evaluation identified an acute mesenteroaxial gastric volvulus. Pediatric surgeons performed an exploratory laparotomy, reduction of the gastric volvulus, and gastropexy, and the patient was discharged after a brief hospitalization. Conclusions: Acute gastric volvulus can present with symptoms similar to benign abdominal etiologies. Timely diagnosis and intervention are key to improved outcomes for patients. Key Words: gastric volvulus, surgery, adolescent, emesis (Pediatr Emer Care 2015;00: 00–00)
irst described in the pediatric population by Oltman in 1899,1 gastric volvulus is not a common diagnosis in this population. A total of 581 cases of pediatric gastric volvulus have been reported in the literature between 1929 and 2007. Of these cases, only 252 were an acute presentation.2 This uncommon diagnosis can be easily overlooked given its similar initial presentation to more common etiologies of pediatric abdominal pain. It is important to keep gastric volvulus in mind when evaluating patients with similar presentations or patients whose complaints do not resolve with the usual therapies, because the sequelae of the missed diagnosis can result in potentially life-threatening events for the patient. Here, we outline a case of a male adolescent who presented to the pediatric emergency department (ED) with vomiting and subsequently whose condition was diagnosed as acute mesenteroaxial gastric volvulus.
F
CASE A Somali-born male adolescent was brought into a tertiary care pediatric ED by his father with a complaint of acute onset of epigastric pain and several episodes of nonbilious, nonbloody emesis because the pain started approximately 5 hours earlier. The patient had a history of mild developmental delay. The patient and his father denied any other medical history or surgical history. The adolescent immigrated to the United States in 2005 with no recent travel outside the country. The patient’s only medication was guanfacine for behavioral issues, and he had no reported allergies. From the *Department of Pediatrics, Walter Reed National Military Medical Center, Bethesda, MD; and †Department of Pediatric Emergency Medicine, UMass Memorial Medical Center, Worcester, MA. Disclosure: The authors declare no conflict of interest. Reprints: Dimas C Espinola, MD, MPS, Department of Pediatrics, Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD 20889 (e‐mail: [email protected]). Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0749-5161
Pediatric Emergency Care • Volume 00, Number 00, Month 2015
On physical examination, his vital signs were stable and his abdomen was soft, not notably distended, and diffusely tender to palpation in the upper quadrants without rebound or guarding. The patient received intravenous fluids, analgesia, and antiemetics. Basic blood work, including a liver profile and a lipase, was unremarkable. An upright abdominal radiograph was ordered, and it showed marked gastric distention with question of recent fluid ingestion but no evidence of small or large bowel obstruction (Fig. 1). After 6 hours of observation, the patient felt better. His abdomen remained soft and nondistended, and the abdominal tenderness, which was attributed to multiple episodes of vomiting, had resolved. The patient had no additional episodes of emesis, and he tolerated oral fluids. The patient was discharged with planned follow-up within 24 hours with his primary care physician. Approximately 5 hours after discharge, the patient again presented with his father to the ED with worsening abdominal pain. The patient described a diffuse burning pain in his upper abdomen, and he was unable to keep food or fluids down because of it. The family stated that the symptoms had started again shortly after discharge earlier that day. Since his discharge, they reported 5 episodes of nonbilious, nonbloody emesis. On physical examination, his vital signs were stable, but his abdomen was firm, obviously distended, and diffusely tender to palpation. Another upright abdominal radiograph showed further distension, with more air in the stomach and less distal gas in the intestine when compared with the previous radiograph (Fig. 2). The finding raised concern for intrinsic versus extrinsic gastric outlet obstruction. A nasogastric (NG) tube was placed and drained approximately 1200 mL of yellow-green fluid; however, his pain persisted. On a scout abdominal radiograph, the gastric distension was not visibly relieved by the NG tube placement, and the NG tube had entered the stomach more inferiorly and medially than expected (Fig. 3). Pediatric surgery was consulted. An abdominal and pelvic computed tomography (CT) scan was ordered. Coronal and axial images were notable for the NG tube entering at the gastroesophageal (GE) junction, with the GE junction more medially and inferiorly positioned than normal (Fig. 4). In addition, the imaging showed pylorus displacement superior and to the left when compared with the normal pylorus location (Fig. 5). These images confirmed that the stomach was rotated, and pediatric radiology confirmed a diagnosis of mesenteroaxial gastric volvulus. The pediatric surgery service took the patient to the operating room for exploratory laparotomy, reduction of the mesenteroaxial gastric volvulus, and gastropexy. There were no complications during the procedure, and the patient was transferred to the pediatric intensive care unit (PICU) for observation and management. During his PICU course, he received ventilatory support for 24 hours and then was successfully extubated. He was transitioned to oral feeds and did well during his remaining PICU course before being discharged home with an appropriate follow-up course.
DISCUSSION Normally, the stomach is fixed in position by the following 4 ligaments: the gastrocolic, gastrohepatic, gastrophrenic, and gastrosplenic ligaments. Either laxity or absence of these ligaments can lead to primary gastric volvulus, whereas secondary www.pec-online.com
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
1
Pediatric Emergency Care • Volume 00, Number 00, Month 2015
Espinola et al
FIGURE 1. Upright abdominal radiograph from the first ED visit with arrow denoting gastric wall margin.
gastric volvulus is the result of gastric anatomic abnormalities or adjacent organ abnormalities.2,5 Etiologies of secondary gastric volvulus include gastric outlet obstruction, diaphragmatic hernia (congenital or acquired), hiatal hernia (most commonly as paraesophageal hernia), asplenia syndrome or severe chronic
FIGURE 2. Upright abdominal radiograph from the second ED visit with arrow denoting gastric wall margin.
2
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splenomegaly, wandering spleen, intestinal malrotation, and abdominal bands or adhesions.2,4 Gastric volvulus is best described as a twisting of the stomach greater than 180 degrees around either its short axis (transecting the greater and lesser curvatures) or long axis (transecting the pylorus and hiatus of the diaphragm). Mesenteroaxial volvulus occurs when the stomach rotates on its short axis, and organoaxial volvulus occurs when the stomach rotates on its long axis.3 A combined volvulus describes a gastric rotation around both the short and long axes.2 Gastric volvulus can have an acute or a chronic clinical presentation. Acute gastric volvulus typically presents with nonbilious emesis, abdominal pain, and distention and can precipitate respiratory or cardiovascular collapse as a result of increased intrathoracic pressure. Respiratory distress can also result from aspiration pneumonia associated with recurrent emesis.6 The severity of symptoms relates to the degree of rotation, the extent of the resulting gastric obstruction, and whether the stomach can unrotate on its own (intermittent volvulus). A fixed volvulus can result in gastric ischemia, with or without perforation, and with or without possible sepsis. This possibility reinforces the need for quick recognition and surgical intervention in an acute presentation. Mesenteroaxial gastric volvulus carries a higher risk for gastric ischemia due to the anatomy of the rotation in relation to the gastric blood supply.6 Chronic gastric volvulus may present with recurrent abdominal pain, recurrent chest infections, chronic nausea and emesis, and failure to thrive, particularly in younger infants.6 Between 1929 and 2007, only 581 cases of gastric volvulus in the pediatric population are reported in the literature.2 Approximately one fifth of the total reported pediatric gastric volvulus cases are seen in pediatric patients younger than 1 year, and these
FIGURE 3. Scout abdominal radiograph after NG tube placement with arrow denoting the NG tube more inferiorly and medially positioned. © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Pediatric Emergency Care • Volume 00, Number 00, Month 2015
Acute Gastric Volvulus in an Adolescent Male
FIGURE 4. Axial and coronal CT abdomen/pelvis slices identifying the GE junction more medially and inferiorly positioned than normal.
are typically due to congenital diaphragmatic disorders.4 Approximately 80% of cases are reported in patients younger than 5 years.3 Interestingly, less than 5% of pediatric cases occurred in adolescents.2 This age differential could be due to the fact that existing congenital or anatomical defects would tend to predispose to a presentation in a much younger pediatric age group. The fifth decade of life is the peak incidence for gastric volvulus,4 and 30% of these adult patients present with Borchardt’s triad of epigastric distention, an inability to pass the NG tube, and intractable retching.3 Of 252 acute pediatric gastric volvulus cases reported between 1929 and 2007, 54% were organoaxial, 41% were mesenteroaxial, and 2% were combined.2 In addition, the acute cases tended to present earlier in life, with approximately 21% appearing in the first month, 58% appearing in the first 12 months, and 85% by the age of 5 years.2 The reported incidence in adolescents aged 13 to 18 years was only 4%,2 which translates to a total of 10 adolescent patients during this 78-year period of reporting. The treatment and outcome of the acute cases were related, in part, to the frequency of need for acute resuscitation in this group, with surgical repair reported in almost 90% and a mortality rate of less than 7% overall.2 Of the 252 acute presentations, 47 patients (approximately 19%) did have a history suggestive of previous
chronic intermittent volvulus.2 These chronic presentations are associated with spontaneous correction of the gastric volvulus but can transition to an acute gastric volvulus if the orientation of the stomach does not correct itself.5 A slight majority of the reported pediatric cases in the literature (57%) do present as chronic, recurrent, or intermittent with a striking predominance (74%) being of primary etiology. Of 329 chronic clinical presentations, 85% were of the organoaxial type, 10% were mesenteroaxial, and 3% were combined.2 Interestingly, when looking at chronic gastric volvulus, Cribbs et al2 suggest that differing rates of diagnosis and treatment approaches exist when comparing the United States with Africa, Asia, and Europe. The authors suggest that these differences may, in part, be due to the common empiric treatments of gastroesophageal reflux disease in the United States, compared with other countries where the more frequent use of upper gastrointestinal studies may detect the otherwise unsuspected condition of chronic gastric volvulus.2 In our case, the patient presented as a previously healthy, thriving male adolescent with nonbilious vomiting, epigastric pain, and no previous reported episodes of similar symptoms, during a time of the year when many patients were presenting with gastroenteritis. Of note, he described upper abdominal pain, multiple episodes of
FIGURE 5. Axial and coronal CT abdomen/pelvis slices identifying pylorus displacement superiorly and to the left. © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
3
Pediatric Emergency Care • Volume 00, Number 00, Month 2015
Espinola et al
nonbilious and nonbloody emesis over the course of several hours, and the inability to tolerate oral intake but no diarrhea. His initial ED visit seemed unremarkable and consistent with early gastroenteritis, and he was discharged home with instructions for close follow-up after tolerating an oral challenge and feeling better after a few hours. However, his return within a few hours with renewed vomiting and abdominal pain, along with new-onset abdominal firmness and distention raised our suspicions for a more serious etiology. The degree of progressive gastric distension was remarkable. On subsequent review of the initial presentation and radiographs, pediatric radiology commented on the lack of specific findings to suggest the diagnosis of gastric volvulus. On the initial abdominal radiographs (Fig. 1), the stomach size was consistent with a recent fluid ingestion, a hypersecretory state, or a bezoar causing gastric outlet obstruction. Hindsight, in combination with the progression of symptoms, serves to emphasize the importance of a broad differential diagnosis, close patient follow-up after discharge, and clear communication to patients and families regarding concerning signs and symptoms, such as indications for return to the ED. In this case, management included NG tube placement that did not alleviate his symptoms, subsequent additional definitive radiographic imaging that confirmed a mesenteroaxial gastric volvulus, emergent pediatric surgery intervention, and postoperative monitoring before hospital discharge.
CONCLUSIONS While quite uncommon in the pediatric population, gastric volvulus should be considered in the differential diagnosis of
4
www.pec-online.com
pediatric patients presenting with abdominal pain, emesis, lack of “viral” symptoms, an atypical response to the usually effective symptomatic treatment, and an abnormal abdominal physical examination or unexpected abdominal radiography findings. In such presentations, the case outlined here emphasizes the importance of physical examination changes over time and the importance of additional imaging in these situations. In addition, the question of whether chronic intermittent gastric volvulus is often “missed” in US pediatric patients is provocative; however, the presentation of acute versus chronic gastric volvulus seems to be qualitatively distinct. In particular, accurate diagnosis and timely intervention in acute gastric volvulus are key to improved outcomes for patients. REFERENCES 1. Oltman H. Inaugural Discussion. Kiel. 1899. 2. Cribbs R, Gow K, Wulkan M. Gastric volvulus in infants and children. Pediatrics. 2008;122:e752–e762. 3. Mayo A, Erez I, Lazar L, et al. Volvulus of the stomach in childhood: the spectrum of disease. Pediatr Emerg Care. 2001;17:344–348. 4. Godshall D, Mossallam U, Rosenbaum R. Gastric volvulus: case report and review of the literature. J Emerg Med. 1999;17:837–840. 5. Darani A, Mendoza-Sagaon M, Reinberg O. Gastric volvulus in children. J Pediatr Surg. 2005;40:855–858. 6. Tillman BW, Merritt NH, Emmerton-Coughlin H, et al. Acute gastric volvulus in a six-year-old: a case report and review of the literature. J Emerg Med. 2013;46:191–196.
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
