|Year : 2015 | Volume
| Issue : 2 | Page : 154-156
Eventration of diaphragm with gastric volvulus: A case report
John J. S. Martis, Abijith Shetty, Roy Alban Frank, Vijayakumar Vijin
Department of Surgery, Father Muller Medical College Hospital, Mangalore, Karnataka, India
|Date of Web Publication||13-Jul-2015|
Dr. John J. S. Martis
Department of Surgery, Father Muller Medical College Hospital, Kankanady, Mangalore - 575 002, Karnataka
Source of Support: None, Conflict of Interest: None
Gastric volvulus is a rare but potentially life threatening cause for upper gastrointestinal obstruction. It is an abnormal rotation of one part of the stomach around another which can manifest with acute, intermittent or chronic symptoms. Historically first reported case of gastric volvulus was in 1866 by Berti and the first operation for this condition was performed in 1897 by Berg. Since then there are approximately 400 cases reported in the literature. We report a case of acute gastric volvulus associated with eventration of left hemidiaphragm in a 60 years old female who presented with features of gastric outlet obstruction.
Keywords: Eventration of hemidiaphragm, gastric volvulus, gastropexy
|How to cite this article:|
Martis JJ, Shetty A, Frank RA, Vijin V. Eventration of diaphragm with gastric volvulus: A case report. Muller J Med Sci Res 2015;6:154-6
|How to cite this URL:|
Martis JJ, Shetty A, Frank RA, Vijin V. Eventration of diaphragm with gastric volvulus: A case report. Muller J Med Sci Res [serial online] 2015 [cited 2021 Jan 19];6:154-6. Available from: https://www.mjmsr.net/text.asp?2015/6/2/154/160692
| Introduction|| |
The term volvulus is derived from latin word volvere, meaning to turn or roll. Gastric volvulus is acquired rotation of the stomach or parts there of more than 180 ° creating a closed loop obstruction.  The laxity of anchoring ligaments of stomach or the presence of diaphragmatic pathology such as diaphragmatic hernia or eventration predisposes to gastric volvulus. The incidence and prevalence is unknown at this time as many cases are chronic and intermittent and often go undiagnosed.  Though rare, gastric volvulus is a true surgical emergency that is life threatening if not recognized and treated quickly. We report a case of acute gastric volvulus associated with eventration of left hemidiaphragm in a 60 years old female treated successfully by surgery.
| Case Report|| |
A 60 year old woman presented to the emergency department with history of epigastric pain associated with nonbilious vomiting of few hours duration. Her general physical examination was unremarkable other than mild dehydration. On abdominal examination there was tenderness in epigastric region. X-ray erect abdomen and ultrasound of abdomen revealed dialated stomach. An emergency C.T.scan of the abdomen was done which revealed superiorly placed thinned out left hemidiaphragm, with alteration of axis of stomach with superior displacement of antrum and pylorus [Figure 1], suggestive of gastric volvulus. Patient was taken up for emergency surgery. At laparotomy it was found that distal stomach was twisted and pyloric end of the stomach was rolled towards cardia [Figure 2] and left hemidiaphragm was thinned out and superiorly displaced [Figure 3] suggestive of gastric volvulus. Untwisting and correction of gastric volvulus, plication of eventrated left hemi diaphragm and anterior gastropexy was done. Her post-operative period was uneventful. Suters were removed on 10 th post-operative day. After three months of follow up patient is asymptomatic.
|Figure 1: CT scan of the abdomen revealing superiorly placed thinned out left hemidiaphragm, with alteration of axis of stomach with superior displacement of antrum and pylorus|
Click here to view
|Figure 2: Intraoperative photograph showing twisting of distal stomach with rolling of pyloric end of the stomach towards cardia|
Click here to view
|Figure 3: Intraoperative photograph showing eventration of left hemidiaphragm|
Click here to view
| Discussion|| |
Gastric volvulus was first described by Berti in 1866 in a female autopsied patient and the first operation was performed by Berg in 1897.  Gastric volvulus is an acquired rotation of the stomach that can lead to partial or total obstruction. It typically occurs in adults and has its peak incidence in the fifth decade of life. The incidences are approximately equal in men and women.  The etiology is unclear but it is usually found in conjunction with anatomic abnormities such as Para esophageal hernias or diaphragmatic eventration. The abnormally wide sub diaphragmatic space in diaphragmatic eventration provides the potential space for abnormal rotation of the stomach around itself. However one third of patients have no associated findings. It is believed that major factors leading to gastric volvulus is laxity of four gastric ligaments: Gastrophrenic, gastrohepatic, gastrosplenic and gastrocolic which anchor the stomach.  Anatomically gastric volvulus can be classified into three types as proposed by Singleton as organoaxial, mesentroaxial and combined.  In organoaxial volvulus the stomach rotates around the longitudinal axis with greater curvature rotating most often anteriorly. In mesentroaxial volvulus rotation occurs around the transgastric line, a line connecting middle of the lesser curvature with middle of the greater curvature. On the basis of clinical features gastric volvulus can again be classified into acute and chronic recurrent type.  The direction and degree of rotation dictate the severity of symptoms. Acute volvulus present like acute obstruction. This process may eventually compromise the blood supply of the stomach leading to gangrene and perforation. Borchardt's triad of vomiting, epigastric pain and inability to pass the nasogastric tube should warn the clinician to consider a diagnosis of acute gastric volvulus.  Diagnosis of gastric volvulus is based on clinical suspicion and early radiological imaging. Currently C.T.scan can lead to an immediate diagnosis with all the anatomic details.
Acute gastric volvulus is a surgical emergency and treatment delay leads to increase morbidity and mortality. Non operative therapy may be successful in selected patients but this does not address the underlying predisposing factors that led to the volvulus. Because volvulus is unpredictable, potentially catastrophic and may recur most authors recommend expeditious surgical intervention with gastric decompression, reduction of volvulus, correction of predisposing factors and fixation of the stomach to prevent recurrence.  The preferred surgical procedure is anterior gastropexy in which the greater curvature of stomach is fixed to the anterior abdominal wall, but if gastric necrosis has occurred partial or total gastrectomy may be required depending on the extent of ischemic injury.  In high risk patients endoscopic decompression and reduction may be option. 
| Conclusion|| |
Acute gastric volvulus is rare and often unrecognized surgical emergency that should be considered in patients who present with severe epigastric pain, nonproductive retching and evidence of a gastric outlet obstruction especially if there is difficulty in passing nasogastric tube. Currently surgical treatment remains the treatment of choice. Because of the relative rarity of this condition an acute episode of gastric volvulus is likely to be misdiagnosed with fatal consequences unless there is always an index of suspicion of this condition.
| References|| |
Sevcik WE, Steiner IP. Acute gastric volvulus: Case report and review of literature. CJEM 1999;1:200-3.
Dogan NO, Aksel G, Demircan A, Keles A, Bildik F. Gastric volvulus due to diaphragmatic eventration and paraesophageal hernia. Turk J Med Sci 2010;40:825-8.
Shah NN, Mohsin M, Khursheed SQ, Farooq SS, Buchh AA, Quraishi AQ. Eventration of diaphragm with gastric volvulus: A case report. Cases J 2008;1:404.
Wastell C, Ellis H. Volvulus of the stomach: A review with a report of 8 cases. Br J Surg 1971;58:557-62.
Carter R, Brewer LA 3 rd
, Hinshaw DB. Acute gastric volvulus. A study of 25 cases. Am J Surg 1980;140:99-106.
Saha S, Jah A, Gupta S. Sudden onset epigastric pain and vomiting. Diaphragmatic hernia with herniation of stomach. Saudi J Gastroenterol 2012;18:71-2.
Wasselle JA, Norman J. Acute gastric volvulus: Pathogenesis, diagnosis, and treatment. Am J Gastroenterol 1993;88:1780-4.
Ellis H. Diaphragmatic hernia - a diagnostic challenge. Postgrad Med J 1986;62:325-7.
Lowenthal MN, Odes HS, Fritsch E. Endoscopic reduction of acute gastric volvulus complicating motor neuron disease. Isr J Med Sci 1985;21:552-3.
[Figure 1], [Figure 2], [Figure 3]