Gastric volvulus with perforation in association with congenital diaphragmatic hernia

Gastric volvulus in children is a rare surgical emergency. We describe 2 cases of gastric volvulus with gastric perforation in association with congenital diaphragmatic hernia. One case presented in infancy after recurrent chest infections with intestinal obstruction. The other case presented in the early neonatal period. Both cases underwent laparotomy with repair of the stomach and diaphragm defect. The first case developed pyoperitoneum postoperatively, was reexplored but succumbed to septicaemia. The second baby had a favourable postoperative outcome.     

Herniation through triple defects of the diaphragm with gastric volvulus

 A rare case of herniation through triple defects in the diaphragm with volvulus of the stomach is reported. Herniation with gastric volvulus was diagnosed preoperatively. Three diaphragmatic defects were detected at surgery. Repair of the defects after reduction of the abdominal contents resulted in an uneventful recovery. Accepted: 4 May 2000     

Wandering spleen: a rare cause of mesenteroaxial gastric volvulus

Gastric volvulus is a rare cause of acute abdomen in children. Usually it is associated with defects such as diaphragmatic hernia, hiatal hernia, eventration, and paralysis of the diaphragm. We report an extremely rare case presenting with acute intractable vomiting and abdominal distention. Passage of a nasogastric tube relieved the symptoms. A history of the ingestion of a large bolus of chewing gum and a suboptimal contrast study were misleading, and there was a delay in diagnosis of 3 days. Later, repeat upper GI fluoroscopy with contrast medium identified mesenteroaxial volvulus of the stomach. Exploratory laparotomy additionally revealed a wandering spleen. Derotation of the stomach with anterior gastropexy was performed. To our knowledge, wandering spleen in association with gastric volvulus has been mentioned only three times before in the literature.     

Delayed presentation of congenital diaphragmatic hernia with intrathoracic gastric volvulus

Background  Gastric volvulus (GV) occurs when the stomach abnormally rotates around one of its axes and is a rare upper gastrointestinal obstruction. We present an unusual case of intrathoracic GV associated with delayed manifestation of congenital diaphragmatic hernia. Methods  A 16-month-old female infant presented with a history of projectile non-bilious vomiting for 2 days and mild hematemesis for the last day. Physical examination showed epigastric fullness and pain with abdominal palpation. Complaints of the patient disappeared on the 2nd day after hospital admission. On the 6th day non-bilious vomiting started again and an epigastric mass was palpable. Contrast study of the stomach after oral barium administration showed the mesenteroaxial volvulus of the stomach. At laparotomy, the association of non-necrotic intrathoracic GV with intrathoracic spleen was confirmed. Moreover, the diaphragm presented a giant posterolateral hernia of the left dome. Diaphragmatic repair was performed in addition to gastropexy and splenopexy. Results  The postoperative course was uneventful and the child was discharged on the 5th post-operative day. On follow up after one month, clinical examination and plain abdominal X-ray were normal. Conclusions  GV is a clinical emergency which can be life-threatening for children. Upper gastrointestinal study and CT scan with contrast meal are helpful in the diagnosis of the lesion. We emphasize prompt surgical therapy to avoid gastric necrosis.     

Neonatal gastric volvulus secondary to rectal atresia

The "upside-down stomach" is a rare form of organo-axial neonatal volvulus, which occurs because of absent or attenuated anatomical anchors and abnormal motility of the stomach. It is considered a surgical emergency that requires immediate correction. We report a previously undescribed etiology of gastric neonatal volvulus caused by an extremely distended transverse colon, secondary to rectal atresia. The etiologic and diagnostic considerations are discussed. Gastropexy in the form of gastrostomy proved to be an effective treatment.     

Intrathoracic gastric volvulus in an infant

Intrathoracic gastric volvulus in infants is a rare surgical emergency. Delays in diagnosis and treatment are life-threatening due to progressive deterioration of the gastric walls. A 3-month-old female was admitted with severe blood-stained vomiting. A radiologic contrast study showed a complete organoaxial intrathoracic gastric volvulus. The stomach was pulled into the abdomen through a xiphoumbilical incision and a Nissen fundoplication was performed. The 3- and 6-month follows-up examinations showed a thriving, asymptomatic child. Correspondence to: C. Del Rossi     

Pleuropneumoblastome kystique de découverte fortuite chez un nourrisson

Pleuropulmonary blastoma is a rare childhood intrathoracic neoplasm, associated with a poor outcome. We report the case of a 7 week-old boy with a pleuropulmonary blastoma classified as type I. Disease was discovered at a chest X-ray performed as a work-up for a benign acute viral bronchiolitis. The final diagnosis was brought by pathology: a bronchopulmonary malformation had not been ruled out by clinical, radiological and macroscopic findings. Pleuropulmonary blastoma is a rare childhood intrathoracic neoplasm, for which the poor outcome and tough diagnosis justify a surgical attitude when an intrathoracic bullous lesion is found in an infant.     

Acute and chronic gastric volvulus in infants and children: who should be treated surgically?

Gastric volvulus was first described by Berti in 1966. Whereas acute gastric volvulus is very rare, chronic gastric volvulus on the other hand is being diagnosed with increasing frequency. This is attributed to the liberal use of barium meal for the evaluation of infants and children with repeated attacks of vomiting and recurrent chest infection. This report describes our experience in the management of 36 infants and children with acute and chronic gastric volvulus. Their medical records were retrospectively reviewed for: age at diagnosis, sex, symptomatology, diagnosis, treatment and outcome. There were 22 males and 14 females. Their ages at presentation ranged from 1 week to 2.5 years (mean 6.7 months). Their symptomatology included repeated attacks of vomiting (30 patients), recurrent chest infection and asthma like symptoms (6 patients), failure to thrive (6 patients), chocking with feeds (3 patients), loose bowel motion (3 patients) and apnoea attack (1 patient). Two presented acutely with intrathoracic gastric volvulus. One of them had recurrent left diaphragmatic hernia while the other had a large paraesophageal hernia. The remaining patients had chronic intraabdominal gastric volvulus. Radiologically, all had organo-axial gastric volvulus except one who had mesenterico-axial gastric volvulus and 33 (97%) of them had demonstrable gastroesophageal reflux. Eleven were treated conservatively because their symptoms were mild to moderate and settled. The two patients with intrathoracic gastric volvulus underwent reduction of the contents, repair of the defect and anterior gastropexy. The remaining patients underwent gastropexy, both fundal and anterior. Intraoperatively, two were found to have diaphragmatic hernia, nine had mobile (non-fixed) spleen, and eight showed mobile stomach with lax ligaments. Post-operatively, all did well and showed good improvement with disappearance of their symptoms and increase in weight. Acute gastric volvulus is very rare. Prompt clinical suspicion and radiological assessment are essential to treat this life-threatening condition. Chronic gastric volvulus on the other hand is more common but under diagnosed. It should be included in the differential diagnosis of infants and children with repeated attacks of chest infection, vomiting and failure to thrive. Barium meal should form part of their investigations. The treatment of chronic gastric volvulus depends on their symptomatology. Those with mild to moderate symptoms should be treated conservatively, while those with persistent and severe symptoms should undergo anterior (to the abdominal wall) and fundal (to the diaphragm) gastropexy without fundoplication.     

Life‐threatening acute gastric dilatation with aorta compression in a 3‐year‐old child

We report a fatal case of acute gastric dilatation in a 3‐year old boy who presented with severe abdominal pain and massive gastric distension in the emergency room. On physical examination the patient was in shock due to acute abdomen and lower limb ischemia. Initial laboratory findings showed multi‐organ failure with acute renal failure and pancreatitis. Abdominal computed tomography (CT) showed marked dilatation of the stomach resulting in compression of the abdominal aorta. The left kidney, spleen and pancreas were not visible on CT due to the necrotic changes. The patient was quickly stabilized by initial volume resuscitation, but suddenly deteriorated immediately after gastric decompression via nasogastric tube, and died from multi‐organ failure 3 h after initial presentation.     

The intermittent and variable features of gastric volvulus in childhood

Acute gastric volvulus (GV) is a rare pediatric emergency that requires prompt surgical detorsion and gastropexy. In order to clarify the clinical and radiologic features of GV, we reviewed eight cases seen over the past 7 years. The symptoms could be classified as acute, chronic, or intermittent, and included a spectrum of gastrointestinal (GI), respiratory, and nonspecific symptoms. When GV was acute or intermittent, the diagnosis was made on the characteristic appearance of plain abdominal radiographs, whereas in chronic GV an upper GI series was most useful. Endoscopy confirmed or suggested the diagnosis in four cases of intermittent or chronic volvulus. Anterior gastropexy was performed in five patients, gastrostomy in two, and gastroduodenostomy in one. None have recurred over 1 to 7 years of follow-up. Intermittent GI or respiratory symptoms of GV may make the diagnosis difficult. Plain abdominal radiographs, upper GI series, and endoscopy aid the diagnosis. Prompt gastric decompression and anterior gastropexy is the recommended treatment.     

Cecal volvulus: a rare cause of bowel obstruction in a pediatric patient diagnosed pre-operatively by conventional imaging studies

Cecal volvulus is an acute surgical condition that is extremely rare in children, with a mortality rate of up to 40%. The clinical symptoms are often non-specific, and pediatric patients frequently have neurological deficits with associated communication difficulties, making the clinical diagnosis extremely challenging. Conventional radiographic imaging studies play a key role in the prospective diagnosis in children. We report a rare case of cecal volvulus in a 12-year-old boy who was diagnosed pre-operatively by abdominal radiographs and a contrast enema.     

Acute mesenteroaxial gastric volvulus and congenital diaphragmatic hernia

The current report describes the case of an 11-year-old girl with Down syndrome who was admitted because of sudden abdominal pain and vomiting. Her symptoms were secondary to severe gastric volvulus associated with congenital diaphragmatic hernia.     

Volvulus complicating dextrogastria in an infant

We report eventration of right hemi-diaphragm resulting in gastric volvulus of the right sided stomach in an infant. The diagnosis of this rare association was made with contrast CT scan. Patient was initially managed with reduction of stomach, plication of right hemi diaphragm, anterior gastropexy and Ladds procedure, but required re-laparotomy after two months for recurrent volvulus.     

Gastric volvulus complicating left hepatic lobectomy

A 9-month-old male infant underwent a left hepatic lobectomy for hepatoblastoma. Gastric volvulus developed postoperatively and was corrected at a second laparotomy. Although left hepatic lobectomy is not an uncommon surgical procedure, this may be the first documented case of gastric volvulus complicating such a procedure. Offprint requests to: J.-H. Chuang     

Syndrome de Stevens-Johnson sévère chez l''enfant : à propos de 4 observations

Stevens-Johnson syndrome is an acute, self-limiting disease of the skin and mucous membranes. Erythema multiforme, Stevens-Johnson syndrome and toxic epidermal necrolysis are all part of a single spectrum illness. We report severe erythema multiform in 4 children aged from 6 to 15 years old. Erythema was mostly related to mycoplasma pneumoniae infection (3/4) and 1 case was attributed to drugs. Two children developed severe sequelae (obliterans bronchiolitis). No patient had recurrent disease. The early use of steroids is still debated, but in our experience it seems to benefit overall. A long term follow-up is necessary with the study of pulmonary function tests and chest X-rays ophtalmologic and dermatologic examination.     

Chronic gastric volvulus: is it so rare?

Gastric volvulus has traditionally been considered a rare entity in children, and standard texts on paediatrics typically make scant reference to it. In our experience, however, careful radiographic study of children with digestive symptoms reveals gastric volvulus to be more frequent than is commonly thought. We report 52 cases of this disorder, and discuss its diagnosis and treatment. Material and Methods. We performed a retrospective study of all children treated for chronic gastric volvulus in our department since 1976. Results. All 52 patients (27 boys, 25 girls) were term infants, mean age 2.8 months at diagnosis. The principal symptoms were crying and colic (90 %), vomiting and nausea (67 %). The mean age at onset of symptoms was 1.1 months. Diagnosis was in all cases on the basis of upper intestinal transit studies. The most frequent radiological signs were high greater curvature (87 %) and greater curvature crossing the oesophagus (83 %). Nine of the 52 children underwent primary surgery. The remaining 43 patients underwent conservative (i.e. postural) treatment; 11 of these patients showed no significant improvement and thus underwent surgery. We performed 20 surgical interventions (19 simple anterior gastropexies and one a percutaneous endoscopic gastrostomy). All patients showed good recovery after surgery. Conclusion. Careful examination of patients with vomiting, abdominal distension, gastro-oesophageal reflux, colic, crying, retarded growth, sleep problems, anxiety, and even repeated respiratory infections will reveal chronic gastric volvulus with greater frequency than has traditionally been thought. We believe that this entity is often undetected, and that, as a result, it is often inappropriately treated.     

Purpura rhumatoïde de l'enfant : à propos de 67 cas

Henoch-Shonlein purpura is a systemic vasculitis with predominance in children; its diagnosis is clinical and prognosis is often favourable. The aim of this study was to precise the epidemiological, clinical profiles and course of disease. The authors studied retrospectively 67 cases enrolled in the paediatrics department of the Fattouma Bourguiba university hospital in Monastir (Tunisia) during 14 years (1990–2003). Children were aged from 3 to 13 years (mean age: 7 years and half) with male predominance (sex-ratio: 1.18). Purpura was observed in all cases. Articular and digestive manifestations were noted respectively in 88.4% and 67.3% of cases. Renal involvement was noted in 17 cases (25.3%); one of them had nephropathy. The Henoch-Sconlein purpura is generally a benign disease. Prognosis depends on the risk digestive complications at the acute phase and renal damage at long-term.     

Varicella and perforation of the stomach

Involvement of the gastrointestinal tract is rare in varicella. We report a previously healthy young girl with perforation of the stomach that appeared to be a complication of varicella. Varicella inclusion bodies were demonstrated at the site of gastric perforations. On surgery, an organoaxial volvulus of the stomach was demonstrated.     

Tumeurs solides malignes néonatales : à propos de 71 cas

Malignant neonatal tumors are rare and comprise 2% of childhood malignancies. Clinical features, histologic types, prognosis were very different from those seen in older children, facing oncologists with diagnostic, therapeutic and ethical problems. PATIENTS AND METHODS: In a retrospective study from January 1987 to January 2004, we reviewed the management of neonates treated at the Institute Gustave Roussy for a malignant solid tumor for whom symptoms started in the first month of life. RESULTS: Seventy-one neonates were treated, comprising 1,2% of the overall patients treated during the same period of time. Of these 71 patients, 42 (59%) presented with neuroblastomas, 12 (17%) with mesenchymal tumors, 6(8%) with cerebral tumors and 11 with various other types of tumors. Fifty-nine patients underwent surgical resection. Thirty-eight neonates received chemotherapy, administered at a 30 to 50% reduced dose. Hematologic toxicities and infections were the main therapeutic complications. Very small doses of radiotherapy were used in only 5 children. There has been no therapy-related mortality. Twenty-two of the 57 survivors have sequelae, especially patients with intraspinal neuroblastoma. The 5 year overall survival was 79%. CONCLUSIONS: Neonatal malignant solid tumors, except for cerebral tumors, have a good prognosis. The young age of patients resulted in problems of treatment tolerance. The therapeutic regimen should take into account the risk of acute iatrogenic toxicity and long term sequelae. Surgery remains the treatment of choice but chemotherapy, with dose reduction, managed by expert teams, is essential and safer in a lot of case.