Gastric Volvulus in Childhood

MICHA N. ZIPRKOWSKI AND RITA LITTLEWOOD TEELE1

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Gastric volvulus, organoaxial or mesenteroaxial, Is an un- aspiration. Abdominal radiographs were interpreted as normal.
common cause of upper gastrointestinal obstruction in child- Over the next 2 weeks the vomiting persisted and was associ-
hood. It may be suspected on plain radiographic examination ated with increasing dyspnea and cyanosis. Exploration of the
of the abdomen and confirmed by upper gastrointestinal abdomen was planned but was postponed because of the
series. Seven affected chIldren are described. In childhood, pulmonary disease and death occurred 16 days after admission.
gastrIc volvulus often coexists with mesenteric abnormalities Review of the abdominal radiographs after the patients death
or with lesions that lead to distention of the gastrointestinal revealed findings consistent with intermittent organoaxial vol-
tract. vulus of the stomach (fig. 1). This had not been recognized
before death; rather, it was the pulmonary disease, the result of

Most of the literature concerning gastric volvulus has vomiting and aspiration, that drew most attention.

dealt with this entity in adults. Recently, several publica-

Case 3
tions have described it in children [1-4]. Seven patients
E. L., a 3-year-old girl, had been admitted twice to another
with gastric volvulus have been seen in this department
hospital for treatment of acute gastric distention. During the
over 17 years; five of the seven were seen in the past 2
second admission, perforation of the stomach occurred which
years. Three of the seven patients had associated mes- required surgical closure. Several episodes of abdominal dis-
enteric abnormalities; three had a condition that led to tention ensued over the next 2 months and she was referred to
distention of the gastrointestinal tract; and in one, an our hospital. Review of the radiographs (fig. 2) resulted in a
underlying abnormality was not elucidated. The signifi- diagnosis of mesenteroaxial gastric volvulus. Subsequently, it
cant clinical and radiographic findings are discussed in was reduced surgically and a gastropexy was performed. Be-
this report. cause of persistent abdominal distention, another upper gas-
trointestinal series was done several months later. This showed
Case Reports a tracheoesophageal fistula which was ligated.
Case 1 Case 4
T. B., a 13-month-old boy, known to have asplenia, single A. M. a 20-year-old
, retarded female, was referred because of
atrium, single ventricle, and a left Blalock-Taussig shunt per- a 2 year history of episodic vomiting and abdominal distention.
formed at age 1 1 months, was admitted because of acute onset An upper gastrointestinal series revealed a partially obstructing
of vomiting followed by lethargy and shock. Physical examina-
tion revealed a distended, tender abdomen. A large mass was
palpated in the left upper quadrant. Hematest positive fluid (150
ml) was aspirated from the stomach; the abdomen became soft
and the mass disappeared. A few hours later, abdominal disten-
tion recurred and aspiration of the stomach yielded 250 ml of
blood. Radiography of the abdomen strongly suggested, and an
upper gastrointesti nal series confirmed mesenteroaxial
, volvu-
lus of the stomach. At surgery there was malrotation of the
bowel and absence of both gastrosplenic and gastrohepatic
ligaments in addition to the gastric volvulus. Lysis of duodenal
bands and a gastropexy were performed.

Case 2

B. C. a 5-month-old
, girl, was admitted for the second time
because of intermittent vomiting, poor growth, and chronic
cough. At her first admission at age 4 months for similar
symptoms, an upper gastrointestinal series demonstrated mal-
rotation of the bowel. At surgery, duodenal bands were lysed,
the small bowel was placed in the right hemiabdomen, and the
colon was placed in the left hemiabdomen (Ladds procedure).
However, hen symptoms were not relieved.
At readmission, physical examination revealed a pale, thin
Fig. 1.-Case 2. Upright film from upper gastrointestinal series.
infant; no abnormalities of the chest or abdomen were noted.
Transverse position of stomach, inferior location of esophagogastnic
Radiographic examination of the chest was abnormal and the junction (arrow), and distorted duodenum-typical features of organoax-
parenchymal alterations were felt to be consistent with chronic ial volvulus.

Received September 1 1 , 1978; accepted after revision February 27, 1979.

Department of Radiology, Childrens Hospital Medical Center, Harvard Medical School, 300 Longwood Avenue, Boston, Massachusetts 02115.
Address reprint requests to R. L. Teele.

AJR 132:921-925, June 1979 921 0361-803X/79/132&-0921 $0.00

cc l979American Roentgen Ray Society
 922 ZIPRKOWSKI AND TEELE AJR:132, June 1979
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A
organoaxial volvulus. Itispresumed that aerophagia resulted in admission to our hospital, an intensive investigation was under-
chronic distention of the stomach which predisposed this pa- taken to explain his signs and symptoms. There was evidence
tient to volvulus. of a neunologic disorder as manifest by opisthotonic posturing,
clenching of the fists, and decreased sensory response. Aero-
Case 5
phagia was thought responsible for chronic distention of his
A. P., a 5-month-old boy, had been hospitalized several times gastrointestinal tract. Partial organoaxial volvulus of the stom-
because of vomiting, dehydration, and failure to thrive. On ach, hiatus hernia, gastrointestinal reflux, and aspiration were
 AJR:132, June 1979 GASTRIC VOLVULUS IN CHILDHOOD 923
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Fig. 4.-Case 7.Supine (A) and upright (B) plain abdominal radio-
graphs. Spherical mass in midabdomen with typical beak of mesenter-
oaxial volvulus (arrow), confirmed by upper gastrointestinal series (C).

demonstrated by an upper gastrointestinal series. At surgical the abdomen and an upper gastrointestinal series showed a
exploration of the abdomen, the partial volvulus was reduced; mesenteroaxial gastric volvulus (fig 3). Surgical exploration
fundoplication and gastrostomy were performed. revealed the volvulus and abnormal mesenteric attachment.
Lysis of bands , gastropexy , and a gastrostomy were performed.
Case 6
Case 7
S. F. a 4/-year-oId
, girl, had been admitted many times for
evaluation and treatment of spastic quadraplegia and mental M. I., a 3-year-old boy, experienced recurrent vomiting for 1
retardation The most recent admission
. was related to recurrent year. History included several admissions for management of
nonbilious vomiting. The child was known to be aerophagic. bilateral hydronephrosis and hydroureter. The etiology of the
Physical examination of the abdomen was difficult, but did vomiting was never clear. During a routine hospital visit for
reveal it to be protuberant and tympanitic and a moveable evaluation of his urinary tract, a review of the radiographic
epigastric mass was palpated. The radiographic examination of examinations of the abdomen revealed, on some, evidence of a
 924 ZIPRKOWSKI AND TEELE AJR:132, June 1979

our seven cases, three were organoaxial and four were

mesenteroaxial. In general, torsion of the stomach up to
180#{176}does not result in compromise of the vascular
supply. This degree of torsion has been termed partial
volvulus [6]. Torsion beyond 180#{176} results in complete
gastric obstruction and strangulation of the vasculature.
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Complete volvulus results in the clinical triad first de-

scribed by Borchardt [7]: (1) sudden onset of violent
epigastric pain; (2) intractable retching without produc-
A
tion of vomitus; and (3) inability to pass a tube into the
stomach.
Of the seven patients reported here, three had partial
and four had complete volvulus when first seen. Al-
though one patient had an apparently idiopathic gastric
volvulus (case 7), it is important to note that the other six
had abnormalities associated with, and probably respon-
sible for, the development of the volvulus. Two had
isolated malrotation of the small bowel, one had malro-
tation with asplenia [8], two had gastric distention alone,
and one had both malrotation and gastric distention. As
Fig. 5.-A, Four ligaments that tether stomach:
gastrohepatic, gastrophrenic , gastrosplenic , and gas- mentioned, malrotation results in abnormal mesenteric
trocolic. Retroperitoneal attachment of duodenum attachments. The patient with asplenia also had com-
provides fixation of distal stomach. B, Organoaxial plete absence of the gastrosplenic ligament. In adults,
volvulus. Stomach twists around its long axis. C,
Mesenteroaxial volvulus. Stomach rotates around axis gastric distention that may be associated with volvulus is
joining lesser and greater curvatures. usually secondary to obstruction of the gastric outlet
from ulceration or tumor [9-11]. Two patients with gas-
tric distention reported here were mentally retarded and
mesenteroaxial gastric volvulus (fig. 4). It was found that these aerophagic: intermittent partial gastric volvulus may be
films had been made at the time of an acute episode of vomiting. more common than is recognized in retarded patients.The
Because of the intermittent nature of the gastrointestinal prob- third patient with gastric distention had the unusual
em and because the patient was currently asymptomatic, it was situation of having a tracheoesophageal fistula without
decided to follow the patient clinically. chronic pulmonary disease.
Plain radiographs and upper gastrointestinal series are
Discussion
obviously of help in making the diagnosis of gastric
The stomach is an irregularly shaped viscus that ox- volvulus. In mesenteroaxial volvulus, the distended
pands and contracts several times daily. Its tethering stomach appears spherical on supine films (fig. 2A). On
ligaments must allow these extremes, yet be taut enough upright films, there is often a double fluid level: one in
to prevent torsion as the stomach changes shape. The the fundus which is inferior and the other in the antrum
gastrophrenic ligament and the retroperitoneal attach- which is superior (fig. 3). Also on the upright film, and
mont of the second part of the duodenum provide the occasionally on supine films, gaseous distention of the
superior and inferior fixation. The gastrohepatic liga- inverted antrum, pylorus, and proximal duodenum pro-
ment tethers the lesser curve, the greater omentum duces a beak
where the esophagogastric junction is
(gastrocolic ligament) connects stomach to transverse seen in normals (fig. 4). If a nasogastric tube is passed,
colon, and the gastrosplenic Iigamenttethers the greater the gastroesophageal junction is seen inferior to its
curve (fig. 5A). For a volvulus to occur, these ligaments normal location (fig. 3B). If barium gets past the eso-
must be absent or stretched. Dalgaard [5], working with phagogastric junction, upper gastrointestinal series con-
cadavers, showed that the normal stomach could be firms the upside down position of the stomach and
rotated 180#{176}
by cutting the gastrosplenic or gastrocolic documents the degree of obstruction. If enough barium
ligament or both. In cases of malrotation, the colon is in passes out of the stomach, the position, normal or
an abnormal location and the gastrocolic ligament is abnormal, of the ligament of Treitz can be determined.
deficient. Dalgaard also demonstrated the ease with The diagnosis on plain films of organoaxial volvulus is
which one could twist a large fluid-filled stomach com- not easy. It may be missed on an upper gastrointestinal
pared with an empty one. Thus, those conditions which series as well if careful attention is not paid to the
result in gastric distention also predispose the patient to position of the esophagogastric junction which is lower
gastric volvulus. than normal (fig. 1). The stomach is positioned horizon-
Two types of volvulus may occur: (1) organoaxial, in tally, there is no characteristic beak, and the upright
which the stomach rotates around an axis joining the film often shows just one air-fluid level. Organoaxial
esophagogastric junction and pylorus (fig. 5B); and (2) volvulus was seen in two retarded patients who had
mesenteroaxial, in which the rotation occurs around an distention of the entire gastrointestinal tract from
axis joining the lesser and greater curves (fig. 5C). Of aeorophagia. The distended transverse colon may en-
 AJR:132, June 1979 GASTRIC VOLVULUS IN CHILDHOOD 925

courage volvulus of the stomach on its long axis in these 4. Kilcoyne RF, Babbitt DP, Sakaguchi 5: Volvulus of the
patients [12]. stomach. Radiology 1 03 : 1 57-1 58, 1972
The diagnosis of gastric volvulus should be considered 5. Dalgaard JR : Volvulus of the stomach . Acta Chir Scand 103:
in any child who has acute abdominal pain, retching, 131-153, 1952
6. DeLorimier AA, Penn L: Acute volvulus of the stomach
and gastric distention. Plain films taken before de-
emphasizing management hazards. AJR 77 : 627-633, 1957
compression of the stomach with nasogastric tube often
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7. Borchardt M: Zur Pathologie und Therapie des Magen

make the diagnosis evident. Gastric distention and mes-
Volvulus. Arch KIm Chir 74 : 243-260, 1904
enteric abnormalities predispose a child to gastric vol- 8. MolIer JH, Amplatz K, Wolfson J: Malrotation of the bowel
vulus. in patients with congenital heart disease associated with
splenic anomalies. Radiology 99 : 393-398, 1971
9. DaCosta JC: Modern Surgery. Philadelphia, Saunders,
1931, p877
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