Ann Thorac Surg 2010;89:e15-e16. doi:10.1016/j.athoracsur.2009.12.026
© 2010 The Society of Thoracic Surgeons
Case Reports
"Gastric Bascule": An Unusual Form of Gastric Volvulus
Amber Menezes, MDa,
Leigh Sowerby, MDa,
Richard A. Malthaner, MD, FRCS(C)b,
Neil G. Parry, MD, FRCS(C)a,c,*
a Division of General Surgery, Department of Surgery, The University of Western Ontario, London, Ontario, Canada
b Division of Thoracic Surgery, Department of Surgery, The University of Western Ontario, London, Ontario, Canada
c Division of Critical Care, Department of Surgery, The University of Western Ontario, London, Ontario, Canada
Accepted for publication December 7, 2009.
* Address correspondence to Dr Parry, Department of Surgery, 800 Commissioners Rd E, PO Box 5010, London, ON N6A 5W9, Canada (Email: neil.parry{at}lhsc.on.ca).
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Abstract
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Gastric volvulus can occur along the organoaxial axis or the mesenteroaxial axis. We present a patient with a gastric bascule: a gastric volvulus due to two lead points. A 17-year-old boy with dextrogastria, asplenia, and left diaphragmatic eventration presented with acute onset of nonbilious emesis, jaundice, and diffuse abdominal tenderness. Surgical exploration demonstrated a gastric volvulus, with lead points of torsion at the gastroesophageal junction and the second part of the duodenum, causing biliary obstruction. After decompression, reduction, and gastropexy, the patient recovered well. Gastric bascule is a subtype of gastric volvulus, whereby two lead points cause gastric rotation and folding of the stomach upon itself.
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Introduction
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Gastric volvulus refers to torsion of the stomach that causes gastric obstruction or strangulation with rotation greater than 180°. Rotation can occur along the longitudinal (organoaxial) axis, the transverse (mesenteroaxial) axis, or both (mixed). This disease requires prompt diagnosis and management because acute presentation is life-threatening. Acute gastric volvulus can cause complete obstruction at the gastroesophageal junction, or the gastroduodenal junction, or both [1]. We present a patient with gastric volvulus occurring concurrently at these sites, leading to what we have termed "gastric bascule."
We report a case of a 17-year-old boy with a complex medical history. The patient was born with cerebral palsy, asplenia, total anomalous pulmonary venous return, and situs inversus ambiguous with dextrocardia and dextrogastria. He has had recurrent small bowel obstructions, with one episode complicated by small bowel perforation, and an esophageal ulcer leading to jejunostomy tube insertion.
The patient presented with a 24-hour history of nonbilious emesis, abrupt onset of abdominal discomfort, and difficulty tolerating oral intake. He was jaundiced, with a diffusely tender abdomen. An abdominal roentgenogram performed after nasogastric tube insertion revealed the nasogastric tube curling upon itself, apparently above the diaphragm (Fig 1). Computed tomography imaging revealed distension of the esophagus tapering into extensive distension of the stomach in the left upper quadrant, along with marked intrahepatic duct dilation (Fig 2). The features observed clinically and on the computed tomography scan were consistent with a gastric volvulus.
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Fig 1. Abdominal roentgenogram with the patient supine reveals dextrogastria, significant gastric distension, and curling of the nasogastric tube upon itself above the gastroesophageal junction.
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Fig 2. Computed tomography scan of the abdomen in coronal section demonstrates torsion of the esophagus, leading to immense gastric distension in the left upper quadrant. Note is also made of dilated intrahepatic ducts caused by common bile duct obstruction. The arrow is pointing to the esophageal lumen proximal to the torsion.
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An urgent laparotomy was undertaken. A significantly distended stomach was found in the left upper quadrant, with the distal esophagus and the second part of the duodenum acting as two lead points for volvulus. The left diaphragm was eventrated. The esophagus, containing the nasogastric tube, was to the right of midline directly beside the second part of the duodenum, which was located to the left of midline. The stomach had thus folded back upon itself up into the left upper quadrant.
After gastric reduction, nasogastric tube advancement and decompression were possible. Esophagoscopy revealed mucosal ischemia of the distal esophagus proximal to the gastroesophageal junction. This area was buttressed with healthy esophageal tissue and an omental patch. An anterior gastropexy and Stamm gastrostomy were performed.
The patient's gastric and biliary obstructions resolved postoperatively. Follow-up barium swallow showed no evidence of esophageal stricture or perforation. During the year, however, an esophageal stricture requiring repeated dilation developed and he ultimately required a distal esophagectomy.
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Comment
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First described by Berti [2] in 1866, gastric volvulus can present in acute or chronic forms. The Borchardt triad of intractable retching, epigastric pain, and inability to pass a nasogastric tube has been used to describe the presentation of acute gastric volvulus and has been reported in most adult cases [3]. Clinical features in childhood are often nonspecific, however, ranging from acute onset of vomiting, chest pain, and dysphagia to acute respiratory distress [4]. Interestingly, our patient also presented with jaundice. As one of the lead points was the second part of the duodenum, the common bile duct was also obstructed, which was an unusual presentation in gastric volvulus.
The stomach is normally fixed in position through ligamentous attachments of the gastrohepatic, gastrophrenic, gastrocolic, and gastrosplenic ligaments. Predisposing factors for gastric volvulus include congenital ligament laxity or absence, diaphragmatic eventration, and intestinal malrotation [5]. The combination of dextrogastria, asplenia, and an elevated left hemidiaphragm in this patient allowed for rotation of the stomach into the left upper quadrant. The gastroesophageal junction and the second part of the duodenum were adjacent to each other. This allowed them to act as lead points, which in turn allowed the stomach to flip upon itself up into the left upper quadrant. We propose that this form of gastric volvulus is a "gastric bascule."
The term "bascule" has been applied to describe one type of cecal volvulus. A cecal bascule occurs where hypofixation and massive distension causes the cecum to fold onto itself. Similarly, our patient demonstrated a gastric bascule: asplenia, ligament absence, elevated left hemidiaphragm, and concurrent points of torsion at the gastroesophageal junction and the second part of the duodenum all contributed to gastric distension and rotation of the stomach into the left upper quadrant and onto itself.
Treatment for gastric bascule is similar to other forms of gastric volvulus. The common approach to surgical treatment involves decompression, reduction of gastric herniation, resection of necrotic regions, hernial sac resection, repair of diaphragmatic crural defect, fixation by gastropexy or gastrostomy, or both, and fundoplication if indicated.
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References
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- Elhalaby EA, Mashaly EM. Infants with radiologic diagnosis of gastric volvulus: are they over-treated? Pediatr Surg Int 2001;17:596-600.[Medline]
- Berti A. Singolare attortigliamento dell'esofago col duodeno seguito da rapido morte Gaz Med Ital 1866;9:136.
- Borchardt M. Zur pathologie und therapie des magen volvulus Arch Klein Chir 1904;74:243-260.
- Mayo A, Erez I, Lazar L, et al. Volvulus of the stomach in childhood: the spectrum of the disease Pediatr Emerg Care 2001;17:344-348.[Medline]
- Oh SK, Han BK, Levin TL, et al. Gastric volvulus in children: the twists and turns of an unusual entity Pediatr Radiol 2008;38:297-304.[Medline]
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Abstract
Introduction
