Child With Profound Gastric Distension.

A healthy 3-year-old girl presented to the emergency department with 1 day of intractable, nonbloody, nonbilious emesis, and decreased oral intake and urine output. On examination, she was ill appearing, with a markedly distended and diffusely tender abdomen. Abdominal radiographs were obtained (Figures 1 and 2).Figure 2Left lateral decubitus abdominal radiograph with demonstration of an air fluid level (arrow).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Organoaxial gastric volvulus. Abdominal radiographs revealed a massively distended stomach with an air fluid level concerning for gastric outlet obstruction. A nasogastric tube was placed for gastric decompression, and an upper gastrointestinal series demonstrated a dilatated proximal stomach and no contrast emptying. Furthermore, the rotation of the stomach was abnormal (Figure 3). The pylorus and small bowel were never visualized. The patient was taken to the operating room for diagnostic laparoscopy. An organoaxial gastric volvulus without necrosis or perforation was appreciated. The volvulus was reduced and gastropexy with gastrostomy tube placement was performed without complication. Acute gastric volvulus in the pediatric population is extremely rare.1Mirza B. Ijaz L. Sheikh A. Gastric volvulus in children: our experience.Indian J Gastroenterol. 2012; 31: 258-262Crossref Scopus (11) Google Scholar, 2Porcaro F. Mattioli G. Romano C. Pediatric gastric volvulus: diagnostic and clinical approach.Case Rep Gastroenterol. 2013; 7: 63-68Crossref PubMed Scopus (14) Google Scholar, 3Tillman B.W. Merritt N.H. 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: 191-196Abstract Full Text Full Text PDF Scopus (12) Google Scholar, 4Al-Salem A. Acute and chronic gastric volvulus in infants and children: who should be treated surgically?.Pediatr Surg Int. 2007; 23: 1095-1099Crossref PubMed Scopus (37) Google Scholar Without a high index of suspicion and prompt surgical intervention, the mortality can be as high as 80%.5Gerstle J. Chiu P. Emil S. Gastric volvulus in children: lessons learned from delayed diagnosis.Semin Pediatr Surg. 2009; 18: 98-103Crossref PubMed Scopus (25) Google Scholar The classic appearance of organoaxial gastric volvulus on an abdominal radiograph is an “upside-down stomach,” in which the stomach rotates on a longitudinal access, resulting in the greater curvature resting superior to the lesser curvature (Figure 3).6Cribbs R.K. Gow K.W. Wulkan M.L. Gastric volvulus in infants and children.Pediatrics. 2008; 122: e752-e762Crossref PubMed Scopus (103) Google Scholar,7Park W.H. Choi S. Suh S. Pediatric gastric volvulus: experience with 7 cases.J Korean Med Sci. 1992; 7: 258-263Crossref PubMed Scopus (21) Google Scholar Definitive diagnosis is made with an upper gastrointestinal series, which reveals the gastric rotation and degree of obstruction.2Porcaro F. Mattioli G. Romano C. Pediatric gastric volvulus: diagnostic and clinical approach.Case Rep Gastroenterol. 2013; 7: 63-68Crossref PubMed Scopus (14) Google Scholar Ultimately, the patient should be taken to the operating room urgently for reduction and prevention of complications, including gastric necrosis, peritonitis, shock, and death.6Cribbs R.K. Gow K.W. Wulkan M.L. Gastric volvulus in infants and children.Pediatrics. 2008; 122: e752-e762Crossref PubMed Scopus (103) Google Scholar