|Year : 2013 | Volume
| Issue : 2 | Page : 53-56
Acute gastric volvulus with torsion wandering spleen: A rare surgical emergency
Jagdish Gupta, Navneet Sharma, Bhavesh Devkaran, Arun Gupta
Department of General Surgery, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
|Date of Web Publication||15-Jan-2014|
Department of General Surgery, Indira Gandhi Medical College, Shimla, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
Gastric volvulus, wandering spleen and eventration of diaphragm share a common pathologic cause of absence or laxity of intraperitoneal ligaments. We hereby present a rare case of a 15-year-old male child with cerebral palsy presenting with organo-axial type of acute gastric volvulus resulting in gangrene of whole of stomach, associated with an infarcted wandering spleen, eventration of the diaphragm and cholelithiasis.
Keywords: Eventration of diaphragm, gastric volvulus, wandering spleen
|How to cite this article:|
Gupta J, Sharma N, Devkaran B, Gupta A. Acute gastric volvulus with torsion wandering spleen: A rare surgical emergency. Saudi Surg J 2013;1:53-6
|How to cite this URL:|
Gupta J, Sharma N, Devkaran B, Gupta A. Acute gastric volvulus with torsion wandering spleen: A rare surgical emergency. Saudi Surg J [serial online] 2013 [cited 2019 Mar 21];1:53-6. Available from: http://www.saudisurgj.org/text.asp?2013/1/2/53/125040
| Introduction|| |
Gastric volvulus is a rare clinical condition, first described by Berti in 1866,  Van Horne, a Dutch physician is credited with describing wandering spleen or a hypermobile spleen after performing an autopsy.  Gastric volvulus and wandering spleen share a common cause, the absence or laxity of intraperitoneal visceral ligaments. There are no reports in our knowledge of acute gastric volvulus with gangrene, eventration of diaphragm and wandering spleen with torsion presenting together as an emergency.
| Case Report|| |
The present case report is about a 15-year-old male child who presented in emergency with moderate to severe upper abdominal pain, bilious vomiting followed by unproductive retching and abdominal distention for 2 days. The patient was a known case of cerebral palsy since birth. There was a past history of recurrent upper abdominal pain for the last 5 years in epigastric region, which used to be sudden in onset, dull aching in nature, non-radiating, moderate in intensity, with no aggravating factors and relieved spontaneously. On examination, the patient was irritable, restless and un-cooperative. There was mild tachycardia, tachypnea and moderate dehydration. An intra-abdominal lump of size 8 × 5 cm in epigastric region, with smooth surface, tender, firm, ill-defined margins, limited mobility with respiration and not continuous with liver, was present. There was no hepato/splenomegaly; no free fluid and bowel sounds were sluggish. There was inability to pass a nasogastric tube. The hematological and biochemical parameters were normal. X-ray abdomen standing revealed a distended stomach with an air-fluid level, raised left hemidiaphragm and paucity of distal intestinal gas. Ultrasonography abdomen-showed mass in relation to left lobe of liver in epigasric region of size 9 × 6 cm with cholelithiasis with dilated gut loops. On urgent Contrast enhanced computed tomography abdomen showed spleen was lying anteriorly in the epigastric region [Figure 1], stomach was grossly dilated with thickening of walls and raised left hemidiaphragm [Figure 2]. Gall bladder was full of stones. With a probable diagnosis of acute gastric volvulus with wandering spleen with cholelithiasis patient was explored in emergency. On exploratory laparotomy: Spleen was infarcted, lying in midline in front of stomach [Figure 3]. Organo-axial type gastric volvulus with gangrene of whole of stomach was there. Stomach was massively dilated, contained 1.5 l of hemorragic fluid. Eventration of left hemidiaphragm was seen [Figure 4]. Gall bladder was full of multiple stones.
|Figure 1: Contrast enhanced computed tomography showing spleen lying anteriorly in epigastrium|
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Exploratory laparotomy with total gastrectomy, splenectomy and cholecystectomy with Roux-en-Y esophago-jejunostomy was performed. Post-operative period was uneventful. Patient was discharged on the 12 th post-operative day.
| Discussion|| |
Gastric volvulus is defined as an abnormal rotation of the stomach of more than 180º, creating a closed-loop obstruction.  There are described three types of gastric volvulus according to the axis of rotation: organoaxial, mesenteroaxial and combination.  In organoaxial volvulus the stomach rotates around the longitudinal axis It is the commonest variant and occurs in approximately 59% of cases. In mesentero-axial volvulus rotation occurs around transverse axis. Gastric volvulus can be acute, chronic, or acute on chronic. Chronic gastric volvulus is usually mesentroaxial type, partial, idiopathic and asymptomatic.  Acute gastric volvulus is usually of organoaxial type, total and associated with diaphragmatic hernia or eventration.  The etiology of gastric volvulus is thought to be secondary to laxity or lack of the gastric ligaments. Patients of acute gastric volvulus present with the Borchardt's classic clinical triad comprising of severe epigastric pain, retching without vomiting and the inability to pass a nasogastric tube into the stomach.  The sequence of pathological events are pyloric obstruction (vomiting), followed by obstruction of cardia (inability to vomit and pass nasogastric tube).  Delay in diagnosis may lead to strangulation, perforation, hemorrhage, ischemia and gastric necrosis.  Radiographic findings show gastric distension or double bubble sign.  Computed tomography (CT) scan delineates the transition point. Endoscopic diagnosis can reveal a tortuous appearance of the stomach and difficulty or inability to reach the pylorus.  Gastric volvulus presenting with acute symptoms requires immediate surgical intervention. Gastropexy is done if stomach is viable and healthy. Subtotal/total gastrectomy is proposed when the stomach appears gangrenous. 
Eventration of diaphragm is defined as an abnormally high ascent of an intact diaphragm into the chest. Eventration leads to increase subdiaphragmatic space and provides a potential for gastric rotation.
Wandering spleen is a mobile spleen that is attached only by an elongated congenital malformation resulting from abnormal development of the splenic peritoneal attachments.  Spleen develops during the 5 th week of gestation within the dorsal mesogastrium. The developing spleen divides this into an anterior portion which will develop into the gastrosplenic ligament and a posterior portion, which will develop into the splenorenal ligament [Figure 5]. As the stomach rotates in a clockwise direction the posterior portion of the dorsal mesogastrium (splenorenal ligament) fuses with the peritoneum overlying the developing left kidney, attaching the spleen to the posterior abdominal wall.  Splenic vessels lie in splenorenal ligament. For this reason, the splenic pedicle has an increased risk of axial torsion that can lead to splenic congestion and ultimately to splenic infarction. Torsion complicates 64% of pediatric wandering spleens.  Splenic torsion and can cause vascular congestion, infarction and even gangrene of the spleen. Other complications associated with wandering spleen are hypersplenism, pancreatitis, intestinal obstruction and bleeding from gastric varices. Abdominal sonography shows absence of splenic silhouette in left upper quadrant. Duplex study can be performed to assess splenic blood flow. CT shows an abnormal location of the spleen. Splenopexy is done for viable wandering spleen and splenectomy is done for necrosis of spleen. 
There is a rare association between gastric volvulus, wandering spleen and eventration of diaphragm. These entities share a common cause, the absence or laxity of intraperitoneal visceral ligaments. Prophylactic gastropexy in patients with wandering spleen may therefore be implicated.  The dorsal mesoesophagus and mesogastrium play an important role in the proper development of the diaphragm, gastrophrenic, gastrosplenic, spleenorenal, gastrocolic ligaments and lesser sac.  When one encounters a case of gastric volvulus, he/she should always look for associated the pathology of stomach, gastric ligaments, spleen, colon and for defects in diaphragm. 
Though there are few case reports showing acute gastric volvulus, wandering spleen and eventration of diaphragm, ,, but in none of the patients acute surgical emergencies involving two organs, i.e. acute gastric volvulus with strangulation and torsion of spleen with infarction were present.
There are few studies which report these conditions with cerebral palsy  and cholelithiasis,  These findings could be coincidental or a part of some unknown syndrome. The delay in presentation of our patient could be due to mental retardation.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]