case conference - naresuan university · 2015. 9. 7. · • case term male newborn 38+3 weeks, c/s...
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CASE CONFERENCEGASTRIC VOLVULUS
PIKOM, MD
NONGLUK, MD; RADIOLOGIST
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IDENTIFICATION DATA
• ผู้ ป่วยเดก็ชายไทย อาย ุ13 วนั
• เชือ้ชาติไทย สญัชาติไทย
• ภมิูลําเนา จงัหวดั อทุยัธานี
• เข้ารับการรักษาท่ี รพ.มหาวิทยาลยันเรศวรวนัท่ี 18 พฤษภาคม พ.ศ. 2558
• ประวตัิได้จาก เวชระเบียน
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PRESENT ILLNESS
• CASE TERM MALE NEWBORN 38+3 WEEKS, C/S DUE TO CPD (5/5/58)
• มีอาการอาเจียนเป็นนม และนํา้เขียวๆ หลงักินตัง้แตแ่รกคลอด ถ่าย MACOMIUM1-2 ครัง้/วนั นํา้หนกัลดลง
• PHYSICAL EXAMINATION
• ABDOMEN: SCAPHOID ABDOMEN, SOFT, NO MASS
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INVESTIGATION
• FILM CHEST X-RAY INCLUDE ABDOMEN (8/5/58)• DILATED STOMACH, NOT SEEN AIR IN BOWEL AND RECTUM
• ULTRASOUND ABDOMEN (12/5/58)• NO EVIDENCE OF HYPERTROPHIC PYLORIC STENOSIS
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MANAGEMENT
• NPO
• OG TUBE
• ON TPN
• SENT FOR UPPER GI STUDY
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UPPER GI STUDY
-> Left diaphragmatic elevation (red arrow) -> Air- contrast filled dilated stomach-> Air in bowel loops distal to stomach is seen.
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UPPER GI STUDY
- Antrum (green arrow) superior and higher than gastroesophageal junction (red arrow)- The contrast media cannot pass to duodenum
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DIAGNOSIS
• MESENTERO-AXIAL GASTRIC VOLVULUS WITH PARTIAL GUT OBSTRUCTION
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GASTRIC VOLVULUS
• ROTATION OF THE STOMACH OF MORE THAN 180° AROUND THE AXIS
• CAUSES OBSTRUCTION OF THE GASTROINTESTINAL TRACT
• ROTATION OF THE STOMACH OF <180° THAT LEADS TO ONLY PARTIAL FOREGUT OBSTRUCTION IS DEFINED AS ‘GASTRIC TORSION’
• GENERALLY CONSIDERED RARE IN THE PEDIATRIC POPULATION
• DEFINITIVE DIAGNOSIS IS MADE WITH UPPER RADIOLOGICAL GASTROINTESTINAL STUDIES
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PATHOPHYSIOLOGY
• STOMACH FIXES BY FOUR LIGAMENTS
• ABNORMAL -> CAN ROTATE ALONG AN AXIS PERPENDICULAR TO ITS LONG AXIS
• ASSOCIATED WITH ELEVATION OF THE LEFT HEMIDIAPHRAGM
• MAY BE OBSTRUCTION OF BOTH THE GASTRIC INLET AND GASTRIC OUTLET
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ANATOMY
From: https://classconnection.s3.amazonaws.com/119/flashcards/690119/jpg/stomach_diagram1318786515876.jpg
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ANATOMY
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ETIOLOGICAL OF GASTRIC VOLVULUS
• PRIMARY GV
• ABSENCE OR LAXITY OF LIGAMENTS ATTACHING THE STOMACH TO THE SURROUNDING STRUCTURES
• SECONDARY GV (ANATOMIC DEFECTS)
• ELEVATION AND DIAPHRAGMATIC HERNIA
• MALROTATION OF GUT - ASPLENIA
• WANDERING SPLEEN - PYLORIC STENOSIS
• TRAUMATIC INJURY TO DIAPHRAGM - PHRENIC NERVE PALSY
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ETIOLOGICAL OF GASTRIC VOLVULUS
From: Pediatric Gastric Volvulus: Diagnostic and Clinical Approach; Case Report in Gastroenterology 2013;7:63–68
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PRESENTATION
• CHRONIC VOMITING, ABDOMINAL DISTENSION, FAILURE TO THRIVE AND RECURRENT CHEST INFECTION
• THE BORCHARDT TRIAD
• SUDDEN EPIGASTRIUM PAIN
• INTRACTABLE RETCHING
• INABILITY TO PASS A NASOGASTRIC TUBE INTO THE STOMACH
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PRESENTATION
From: Pediatric Gastric Volvulus: Diagnostic and Clinical Approach; Case Report in Gastroenterology 2013;7:63–68
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PHYSICAL EXAMINATION
• NONSPECIFIC
• EPIGASTRIC TENDERNESS AND DISTENTION
• PERITONITIS IN CASES OF STOMACH NECROSIS OR SEVERE OBSTRUCTION
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TYPES OF GASTRIC VOLVULUS
• ORGANOAXIAL VOLVULUS
• ROTATE AROUND ITS LONG AXIS
• MORE COMMON THAN MESENTEROAXIAL VOLVULUS
• ASSOCIATION WITH LARGE HIATAL HERNIAS (PARTICULARLY OF THE PARAESOPHAGEAL TYPE)
• MESENTEROAXIAL TYPE
• TRUE EMERGENCY -> TWIST CAN COMPROMISE THE BLOOD SUPPLY TO THE STOMACH
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TWO TYPES GASTRIC VOLVULUS
A -> Gastric ligamentous fixation - Gastrohepatic - Gastrophrenic - Gastrocolic - Gastrosplenic
B -> Rotation of the stomach - Short axis: mesenteroaxial volvulus- Long axis: organoaxial volvulus
From: Gastric volvulus; Caffey Pediatric imaging 11th
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Mesenteroaxial volvulus- Twisting along its short axis - A = gastric antrum- GEJ = gastroesophagealjunction
Organoaxial volvulus - Rotation of the stomach along its long axis- GC = greater curvature - LC = lesser curvature
From: Volvulus of the Gastrointestinal Tract: Appearances at Multimodality Imaging; radiographics, 2009
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• LINE A–A -> ORGANOAXIAL VOLVULUS
• LINE B–B -> MESENTEROAXIAL VOLVULUS
From: Gastric volvulus; Caffey Pediatric imaging 11th
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RADIOGRAPHS
• PLAIN RADIOGRAPHS OF THE CHEST AND ABDOMEN
• LARGE DISTENDED STOMACH BELOW AN ELEVATED LEFT HEMIDIAPHRAGM
• UPPER GASTROINTESTINAL CONTRAST STUDY
• HELP TO DIAGNOSTIC
• DETERMINED THE TYPE OF VOLVULUS
• CT WAS NOT NECESSARY IN EITHER CHILD AND IT DELAYED SURGERY
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Plain radiograph of chest and abdomen -> Left diaphragmatic elevation -> Gastric air shadow in left chest-> Dilated oesophagus-> Gasless abdomen
Upper gastrointestinal contrast study lateral view -> Left diaphragmatic elevation and organoaxial gastric volvulus: - Upside down stomach with reversal of
greater and lesser curvatures- Greater curvature (white arrows) crossing
the esophagus - Gastric outlet obstruction.
From: Neonatal acute gastric volvulus; IMAGES IN NEONATAL MEDICINE; Archives of Disease in Childhood - BMJ Journals, 2003
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• MESENTEROAXIAL VOLVULUS IN A 7-YEAR-OLD GIRL WITH ABDOMINAL PAIN AND DISTENTION
• AT SURGERY, THE VOLVULUS WAS EASILY REDUCED, AND THE DIAPHRAGMATIC ELEVATION WAS REPAIRED.
A -> Lateral chest radiograph - Elevation of the left diaphragm (arrow)
B -> Frontal radiograph: upper GI series - Gastroesophageal junction: normal to slightly low in position - Pylorus superior and higher than gastroesophageal junction
From: Gastric volvulus; Caffey Pediatric imaging 11th
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TREATMENT
• ACUTE GV OFTEN REQUIRES IMMEDIATE SURGICAL TREATMENT
• CHRONIC GV SHOULD BE TREATED CONSERVATIVELY
• PRONE POSITION WITH HEAD SLIGHTLY UP
• PROKINETICS
• ANTISECRETORY DRUGS
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SURGICAL INTERVENTION
• DIAPHRAGMATIC HERNIA REPAIR
• SIMPLE GASTROPEXY
• GASTROPEXY WITH DIVISION OF THE GASTROCOLIC OMENTUM
• PARTIAL GASTRECTOMY
• FUNDOANTRAL GASTROGASTROSTOMY (OPOLZER'S OPERATION)
• REPAIR OF EVENTRATION OF THE DIAPHRAGM
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TAKE HOME MESSAGES
• ROTATION OF THE STOMACH >180° GASTRIC VOLVULUS; <180°‘GASTRIC TORSION’
• ETIOLOGY: PRIMARY (ABSENT OR LAXITY OF LIGAMENT), SECONDARY (ANATOMICAL DEFECT)
• BORCHARHT TRIAD: SUDDEN EPIGASTRIUM PAIN, INTRACTABLE RETCHING, AND CANNOT PASS NG TUBE
• RADIOLOGY: UPPER GI CONTRAST STUDY TO DIAGNOSIS WITH DETERMINED TYPE (ORGANOAXIAL VS. MESENTEROAXIAL)
• TREATMENT: SURGERY VS. CONSERVATIVE
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REFERENCES
• FEDERICA PORCARO; PEDIATRIC GASTRIC VOLVULUS: DIAGNOSTIC AND CLINICAL APPROACH; CASE REPORT IN GASTROENTEROLOGY 2013;7:63–68
• CAFFEY PEDIATRIC IMAGING 11TH ED
• NEONATAL ACUTE GASTRIC VOLVULUS; IMAGES IN NEONATAL MEDICINE; ARCHIVES OF DISEASE IN CHILDHOOD - BMJ JOURNALS, 2003