Gastric volvulus with partial and complete gastric necrosis.

Here, we report two interesting cases of gastric necrosis in acute gastric volvulus due to eventration of the diaphragm. Both the cases presented with a significant challenge and were managed successfully. The management of the cases is presented and relevant literature is discussed. To the best of our knowledge, this is the first case report of gastric volvulus with gastric necrosis requiring complete and partial gastrectomy in the available English literature.

INTRODUCTION

Permanent elevation of either right or left hemidiaphragm in diaphragmatic eventration causes abnormal placement of organs. It may be either congenital or acquired owing to abnormalities in phrenic nerve function. Eventration may be further complicated by acute gastric volvulus, chronic gastric volvulus, or chronic recurrent volvulus of the splenic flexure of the colon.[1] Here, we report two cases of eventration of diaphragm complicated by acute gastric volvulus causing partial and complete gastric necrosis.

CASE REPORTS

Case 1

A 10-month-old male child admitted with features of acute intestinal obstruction with bilious vomiting and occasional hematemesis for last two days. There was difficulty in placing the Ryle's tube even on repeated attempts. The patient was having epigastric fullness. There was history of repeated chest infections in the past for which the patient was treated with antibiotics by a local physician. A babygram showed diaphragmatic defect with a large single air-fluid level [Figure 1]. On exploration, organo-axial gastric volvulus with total necrosis of the stomach was detected [Figure 2] along with eventration of the left hemidiaphragm. The spleen and small bowel were lying high up because of eventration of diaphragm. Total gastrectomy with closure of duodenal stump and esophagojejunostomy (Roux loop) [Figure 3] and jejunojejunostomy was done and diaphragmatic eventration was repaired. The resected specimen was sent for histopathologic analysis. The affected hemidiaphragm was plicated with 3-0 polypropylene stitches in interrupted fashion.

Figure 1

A skiagram of the chest and upper abdomen showing gastric volvulus with eventration of diaphragm

Figure 2

Showing complete necrosis of the stomach

Figure 3

Complete gastrectomy followed by Roux-en-Y esophago-jejunostomy

A postoperative contrast study done on day 5 revealed a smooth passage of dye without leakage or retention. From the same day, feeds were started per oral and the patient tolerated the feeds well. The patient was discharged on the eighth postoperative day. The histopathology report on Haematoxylin and Eosin stain in high power (i.e. 400X magnification) showed necrosis along with infiltration of inflammatory cells.

On follow-up after 15 days, 3 months, and 12 months, the patient is doing well and gaining appropriate weight.

Case 2

A 6-month-old girl was brought to the emergency with sudden abdominal distention, nonbilious vomiting, and restlessness for three days. She did not have any similar history of vomiting, respiratory complaints, or abdominal distension in the past. No similar illness ran in her family. On admission, dehydration was present with a pulse rate of 120/min. Epigastrium was full. Per rectal examination was normal. Straight X-ray revealed left-sided eventration of the diaphragm with prominent gastric bubble with air-fluid levels.

Ryle's tube aspirate was blood-stained and scanty in amount. The patient was resuscitated with intravenous fluids and antibiotics. On exploration, mesenteroaxial volvulus of the stomach was noted. The whole of stomach, sparing the pyloric end, was necrotic. The necrotic stomach was excised and sent for histopathology. Duodenum was mobilized. A pyloric tube was made after pyloromyotomy and oesophago-pylorostomy was performed in a single-layer interrupted fashion with polyglactin 4-0 stitches. Plication of the diaphragm was done with 3-0 polypropylene stitches in an interrupted fashion. Feeding jejunostomy was additionally performed.

Feeding was started from postoperative day 3 through the jejunostomy tube. A contrast study performed after two weeks showed no anastomotic leak Subsequently, the patient was allowed oral diet and discharged. On follow-up 15 days and 6 months later, the patient is doing well.

DISCUSSION

Gastric necrosis due to acute gastric volvulus is rare and not mentioned in detail in English literature. Here, we discuss two very rare and interesting case reports of partial and complete gastric necrosis in patients of gastric volvulus due to eventration of the diaphragm and their successful management. As this condition is very uncommon and has atypical presenting features, its diagnosis becomes difficult for the clinician.

One or more of these three criteria of Borchardt's triad of violent unproductive retching, epigastric fullness, and the inability to pass a Ryle's tube are seen in up to 70% of patients,[23] but was present in only one of our patients (case 1).

In both of our patients, straight X-ray of the abdomen showed the characteristic picture with dilated gastric bubble, absence of any distal gas shadow, air fluid level, and elevation of the left hemidiaphragm, as mentioned in literature.[4]

A few cases of perforation due to gastric volvulus have been reported in literature.[567]

But in both of our patients, volvulus led to extensive ischemia which further caused necrosis of a large segment of the stomach, which had to be sacrificed. To the best of our knowledge, no similar case with such extensive necrosis of stomach has been described in English literature.

Gastric necrosis mandates near total or total gastrectomy with restoration of esophago-intestinal continuity by anastomosis with residual stomach or small intestine. In the first patient, whole of the stomach was necrosed, so Roux-en-Y esophago-jejunostomy and end-to-side jejunojejunostomy was done to restore intestinal continuity as it was the most feasible option.

In the second patient, as a small pyloric part of stomach could be saved, we used residual stomach to make the anastomosis. Both of our patients are thriving, taking small feeds at frequent intervals, and gaining weight.

Gastric volvulus with necrosis in a case of eventration of the diaphragm is a rare phenomenon but must be suspected in order to avoid dreadful consequences. Apart from a thorough history and good clinical examination, an X-ray of the abdomen with the chest in erect posture is needed to clinch an early diagnosis. In case of doubt, an upper gastrointestinal contrast study is helpful.[4] Also, contrast-enhanced computed tomography scan of the chest with 3D reconstruction can clearly show the eventration with gastric volvulus in the chest cavity.[8]

Volvulus is commonly organoaxial, as was seen in case 1, but mesenteroaxial variety (as seen in case 2 in our study) has also been reported.[9] Gastric volvulus has a high mortality rate of 30-50%, and up to 60% when strangulation is present,[10] but both of our patients with gastric necrosis survived as a result of good intraoperative decision and proper postoperative care.

CONCLUSION

In order to prevent the very high morbidity and mortality due to complications of gastric volvulus in a case of eventration of diaphragm, we recommend early diagnosis of the condition, early surgical referral, and urgent surgical intervention.