We present a where mesenteroaxial gastric volvulus with acute pancreatitis presented as an epigastric lump following abdominal trauma in a child with occult left sided eventration of diaphragm. This case is worth reporting due to its rarity and to emphasize the wide range of rare presentation that eventration of diaphragm can produce.
A 6 year old female child presented to pediatric emergency with hemodynamic instability following blunt trauma to the upper abdomen 4 days back, due to fall over a stone while playing. There was history of violent cough following the trauma. Two days after the trauma she developed respiratory distress, abdominal distension and coffee ground vomiting. Abdominal distension was confined to upper abdomen. There was history of constipation for 4 days. There was no history of fever or urinary symptoms. No past history of abdominal or respiratory problems. Pediatricians made a clinical diagnosis of traumatic liver hematoma and pediatric surgical consultation was sought. General physical examination revealed pallor, severe dehydration, tachycardia with low volume pulse and tachypnea. Heart sounds were normal but left basal air entry was grossly diminished. Abdominal examination revealed a soft, tender and resonant epigastric mass with no visible peristalsis. Digital rectal examination was normal. The child was resuscitated and investigated with a presumptive diagnosis of traumatic pseudocyst of the pancreas. However passing a nasogastric tube was difficult, and had to be manipulated 4 times before 900 ml of coffee ground fluid could be aspirated. Erect X-ray abdomen (AXR) showed abnormal course of the nasogastric tube from anterior to posterior direction with tip reaching the left subcostal area (Figure 1A).
There were two air fluid levels in left upper quadrant with no distal bowel gas. The left hemidiaphragm was intact but highly placed at the level of 5th rib, and there was no pneumoperitoneum. All these suggested left sided eventration of diaphragm. The soft epigastric lump with difficulty in passing nasogastric tube and coffee ground aspirate made us to think in terms of associated gastric volvulus also. Ultrasonogram of abdomen showed dilated stomach with full of fluid and food debris with edematous wall. Other visceral organs were normal and pancreas was obscured by bowel gas. It also demonstrated paradoxical movement of the left hemi diaphragm confirming eventration. Hence, the diagnosis of acute gastric volvulus with eventration was considered a high possibility. Gastroesophagogram (Figure 1B) with water soluble contrast showed pylorus to be posterior and highly placed with GE junction lying low and anterior to pylorus suggestive of mesenteroaxial gastric volvulus. Hemogram and renal parameters were normal but serum potassium was low (3.1 mmol/L). The serum amylase was high 324 IU/L (3-13 IU/L). After adequate resuscitation a left upper transverse laparotomy was performed. There was about 50 ml of hemorrhagic free fluid in the peritoneal cavity.
Stomach was grossly dilated and twisted parallel to the mesenteric axis with pylorus lying high and posterior in the left upper quadrant. GE junction was at a lower level and anteriorly placed. However, the stomach was viable without any gangrene (Figure 2A) and the greater omentum showed multiple chalky white nodules of fat necrosis (Figure 2B). Pancreas was located slightly high and more towards left hemidiaphrag with a bulky and edematous head. The left hemidiaphragm was thinned out, floppy and highly placed. All the 4 gastric ligaments were unduly lax. Pylorus, spleen and pancreatic tail were lying in the space created by eventration. The stomach was derotated, contents of the left upper quadrant reduced into the abdominal cavity. Plication of left hemidiaphragm was done with 2-0 prolene interrupted horizontal mattress sutures till adequately flattened. Division of gastrocolic ligament and anterior gastropexy by tube gastrostomy was done for volvulus to prevent recurrence. Peritoneal and lesser sac drains were placed for pancreatitis and a biopsy was taken from the omentum. Postoperative recovery was uneventful. Gastrostomy was removed after 2 weeks. Post operative chest X-ray and upper gastrointestinal contrast study showed adequate flattening of the diaphragm and normal alignment of the stomach. The biopsy of the omentum confirmed the pancreatitis by showing soonification changes (Figure 3). The child recovered well and there is no recurrence of pancreatitis in 6 months follow-up.
Abdominal trauma has been known for long in bringing occult disease to notice. Until otherwise proved, pancreatic pseudocyst becomes an obvious diagnosis in an epigastric swelling following upper abdominal trauma. The differential diagnosis in such situation includes parietal hematoma, hematoma of left lobe of liver, organized collection in lesser sac, pancreatic pseudocyst or an occult mass not related to trauma. However, in the presence of congenital anomalies the differential diagnosis can vary drastically. Probably diaphragmatic anomalies complicate this clinical scenario more than any other anomaly as they can change the anatomy and physiology of not only abdominal viscera but also the thoracic. Plain X – ray abdomen with both domes of diaphragm plays a pivotal role in any abdominal symptomatology, which in our case has made us to diagnose more than what we were dealing with. Left sided diaphragmatic eventration on X-ray has led us to the accurate diagnosis and appropriate management.
Eventration of diaphragm is a common condition with an incidence of 1 in 10,000. Many remain asymptomatic and often mismanaged. There are two types of eventration namely congenital (paralytic & non paralytic) or acquired. Usually it presents with respiratory or GIT symptoms. Congenital diaphragmatic hernia (CDH) has been known to cause several rare abdominal complications like incarceration or strangulation of either small or large bowel, acute appendicitis associated with malrotation, splenic torsion, and gastric volvulus either organo-axial or mesentero-axial with or without perforation.[1,2,3,4]
Similarly, eventration of diaphragm can also predispose to several an abdominal complication amongst which gastric volvulus is common. Gastric volvulus an uncommon condition and more so in the pediatric age is rotation of all or part of the stomach by more than 180º, which may lead to a closed-loop obstruction and possible strangulation. Gastric volvulus may be idiopathic or secondary to various congenital and acquired conditions. Among the associated problems diaphragmatic defects predominate. Stomach is held in its normal position by its natural ligaments, namely, gastrohepatic, gastrophrenic, gastrosplenic and gastrocolic ligaments. Since these ligaments are related to diaphragm, spleen and colon; any problems of these ligaments as such or the adjacent organs can produce volvulus. Not infrequently, gastric volvulus in children fails to exhibit the full gamut of signs and symptoms such as abdominal distension, vomiting, pain, and retching. Borchardt described the classical triad of severe epigastric pain, retching or vomiting and inability to pass nasogastric tube. However, one need not find the classical triad in all the cases. For these reasons, symptomatic gastric volvulus in infancy and childhood may not be as rare as is commonly assumed and early diagnosis and prompt surgical intervention is required to prevent gastric necrosis and perforation. The stomach can undergo volvulus either in the organo-axial (along the long axis of the organ) or mesentero-axial predisposition. Organo-axial volvulus is less common in children and is often seen in association with other predisposing anomalies like eventration, diaphragmatic hernia, hiatus hernia, asplenia, lack of ligaments etc. In eventration, depending on the severity of laxity of diaphragm, the abdominal viscera are under chronic stretch that starts in the intrauterine period. The negative intra-thoracic pressure during each inspiration applies pull on the abdominal viscera and compression on the thoracic viscera. This chronic stretch leads abnormal lengthening of the ligaments that keeps the internal organs fixed to the parietis. Simultaneously this undue stretch not only changes the anatomical position and makes them more prone to volvulus, torsion or trauma but also induces few physiological changes that make the organ more susceptible to described disease like pancreatitis as in CDH.[9,10] Organoaxial volvulus is the commoner and often associated with paraoesophageal hiatus hernia. In patients with eventration of the diaphragm, the colon rise upwards and twist the stomach by pulling on the gastrocolic ligament and causes an organo-axial volvulus. However, in our case the stomach was twisted about the long axis of the gastrohepatic ligament and doubled up on itself causing a mesentero-axial volvulus. This event was probably facilitated by the heavy meal the patient had taken before the onset of symptoms or dilatation of stomach caused by pancreatitis. It has been suggested that a large intake of food causes gastric dilatation and approximation of the pylorus and cardia which promotes mesentero-axial volvulus and is supported by ultrasonographic evidence of fluid and food filled dilated stomach in our case. The pathophysiology in our case can be hypothesized by laxity of all 4 gastric ligaments predisposed pancreas for directly brunt. The trauma would have induced pancreatitis in an already compromised organ due to chronic stretch. The free fluid of pancreatitis with irritants and enzymes in the lesser sac would have induced abnormal gastric dilatation and twisting in a highly mobile stomach due to eventration and lax gastric ligaments. Due to the pull of eventration and stretching of ligaments the pylorus had moved into the region of left chest producing mesentericoaxial gastric volvulus. In corollary the lax ligaments causing stretch of organs and gastric volvulus leading to pyloroduodenal obstruction causing pancreatitis can be an explanation based on the literature description of acute pancreatitis and gastric volvulus occurring in CDH.
Eventration of diaphragm in a child with soft consistency epigastric lump, difficulty in passing nasogastric tube and coffee ground aspirate made us to think in terms of gastric volvulus. Pancreatitis was diagnosed per-operatively though the serum amylase was mildly elevated as it nonspecific and elevation occurs in any acute abdomen and it is rare combination of simultaneous occurrence.
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