2. History
Name: Bhori singh
Age & sex: 45 yrs ,male
Resident :Baroli ,Bharatpur
DOA:05/01/2013
Clinical presentation
Pain abdomen: last 3 days
Abdominal distention: last 3 days
Not passing flatus motion: last 2 days
No h/o fever
No h/o vomiting
3. Cont..
Past history:
No h/o similar complaint
No h/o previous surgery
No h/o DM, TB, COPD, Hypertension , Bronchial
Asthma
Personal history
Smoker
Tobacco chewer
Non alcoholic
Normal bowel bladder habits
14. Post operative follow up
Vitals monitoring
Input /output monitoring
Chest physiotherapy
Skin stitches removal-7th post op. day
Discharge-8th post op. day
15. Discussion
Definition
Gastric volvulus or volvulus of stomach a twisting of
all or part of the Stomach by more than 180 degrees
with obstruction of the flow of material through the
stomach, variable loss of blood supply and possible
tissue death.
16. Cont..
Very uncommon clinical entity
First described by Berti in 1866
Seen in both children and elderly people
Rare below fifth decades of life
17. Classification of gastric volvulus
On the basis of:
1)OnsetAcute
Chronic
2)Axis of rotation Organoaxial
Mesentroaxial
Combined
18. Gastric volvulus
1. Organoaxial(along longitudinal axis-MC)
a)Acute presentation
b)associated with diaphragmatic defects
c)more common in adults
d)vascular compromise more common
2. Mesentroaxial (along vertical axis)
a) recurrent episodes of pain abdomen
b) Diaphragmatic defects are not seen
c) more common in children
3. Combined
20. Aetiology
Type 1 or Idiopathic gastric volvulus
comprises two thirds of cases and is presumably due to
abnormal laxity of the
gastrosplenic*, gastrocolic*, gastrophrenic and
gastrohepatic* ligaments.
21. Cont..
Type 2 or secondary
Type 2 gastric volvulus is found in one third of patients and is
usually associated with congenital or acquired abnormalities
that result in abnormal mobility of the stomach
Diaphragmatic defect
Eventration
Paraoesophagial hiatal defect
Trauma
Paralysis
Congenital bands and adhesions
Intestinal malrotation
Pyloric stenosis and gastric distension
Colon distention
23. Clinical features
Pain abdomen (acute in onset)
Recurrent retching with little vomitus
Inability to pass a Ryles tube
OTHERS
Abdominal pain
Vomiting
Upper GI bleed
Dysphagia
Gastro oesophageal reflux
Respiratory symptoms
Altered bowel habit
Borchardts
Triad
24. Investigations
X Ray FPA- Gas filled viscus in chest and or upper
abdomen, multiple air fluid levels,
Barium contrast studies :sensitive and specific
Upper GI Endoscopy: both diagnostic and
therapeutic
USG
CT scan abdomen and MRI
30. USG:
Peanut sign in a case of chronic gastric volvulus.
The ultrasonographic features consist of a constricted
segment of stomach, with 2 dilated segments located
above and below the constricted part, akin to a peanut.
In several case reports, however, the ultrasonographic
evaluation of gastric volvulus showed normal findings.
32. Advantage of CT Scan
detection of gastric pneumatosis and
pneumoperitoneum, suggestive of necrosis and
perforation, respectively
detection of predisposing factors, e.g. diaphragmatic
defects or hernias, dense adhesions
detection of other abnormalities associated with
gastric volvulus, viz. wandering spleen, intrathoracic
kidney, malrotation with asplenia
excluding other extra-gastric or vascular causes of
gastric ischaemia
33. Limitation of Techniques
Plain radiography may demonstrate findings that are
indistinguishable from those that are produced by
other causes of gastric atony or obstruction.
However, the modality is useful for excluding other
causes of the patient's symptoms, such as
pneumoperitoneum or pneumothorax.
Barium study is highly sensitive and specific.
However, the diagnosis may be missed in cases of
intermittent torsion.
34. Treatment
Aims:
1) Reduction of volvulus
2) Gastric fixation
3) Repair of predisposing factor
Apporach:
Open
Endoscopic
Laproscopic
Combined (endoscopic + laproscopic)
35. Cont..
Open surgery:
Diaphragmatic hernia repair
Division of bands
Gastropexy
Partial gastrectomy(In case of necrosis)
Gastrojejunostomy
Repair of eventration of diaphragm
36. Surgical procedures
Anterior suture gastropexyThe stomach along the
gastro colic omentum is
suspended to the anterior
abdominal wall
Partial gastrectomy –
Indicated if a portion of the
stomach is gangrenous
39. Cont..
Laproscopic
Reduction of volvulus
Anchoring fundus of stomach to diaphragm and
greater curvature of stomach to anterior abdominal
wall
Repair of diaphragmatic defects
fundoplication
40. Cont..
Combined approach
Described by Arben Beqiri in 1997
Less time consuming
Endoscopic T-fasteners are used instead of PEG for
anchoring stomach
42. Method for providing apposition of two
bodily walls
a) forming a puncture site through the two walls;
b) inserting an access cannula into the puncture site;
c) passing a guide tube through the access cannula, the guide tube
retroflexing after passing beyond a distal end of the access
cannula;
d) positioning a distal end of the guide tube proximate one of the
bodily walls;
e) passing a flexible puncturing device through the guide tube and
puncturing the two bodily walls at a second location;
f) connecting a fastener to the puncturing device;
g) retracting the puncturing device to draw the fastener through
the two bodily walls at the second location; and
h) securing the fastener to maintain apposition of the two walls at
the second location.
47. Chronic gastric volvulus
Patient presents with recurrent episodes of vague
abdominal pain and discomfort
Bloating
Surgery is only indicated if the episodes of pain are
severe and disabling
T/t of choice- conservative
Operation of choice-anterior gastropexy
