Hey there, listeners. This is Rod Gerardo from Cincinnati Children's. If you haven't already, download the Stay Current Pediatric Surgery app. Reason I bring it up, episodes like this that are a little bit more visual might do better with some images. So we're gonna give you those images under the media player. You can open up those images while you listen to the podcast. Otherwise, we're gonna give you articles, all sorts of guidelines, resources, things that we want to help you learn along with the audio podcast. So, Download it today, it's in the Apple App Store, it's in the Google Play Store, but until then, enjoy the episode. So today's episode is about a topic that gives me knots in my stomach. I'm talking, of course, about gastric volvulus. OK, seriously though, this is a really rare diagnosis, but it's highly testable and it has some really big implications. So that's why we thought it might be a good time to highlight some of it and to walk us through. We have pediatric surgeon and director of the Colorectal Center at Cincinnati Children's, Doctor Jason Fisher. I've seen it associated with congenital diaphragmatic hernias a few times, and I think that's when we have a high suspicion for it. You see, gastric volvulus is associated with CDH about 17% of the time and associated with evenation of the diaphragm. About 25% of the time. There are some other rare anomalies associated with it as well, but then you also have to keep in mind the age of the patient. 60% happen in the first year of life in the pediatric population, and so about 21% in the first month and over a third in the first year of life. So, Put those together and about 60% of gastric vulvulus cases occur within that first year of life. And when the gastric vulvulus occurs, also is kind of tied to how the patient's gonna present. If the child's like 4 months old, is it more likely, are you're more likely to have an acute problem or a chronic problem? So they're acute. That's Doctor Carolina Pinzon Guzman. She is the fetal surgery fellow at Cincinnati Children's Hospital Medical Center. Usually due to anatomic problems like CDH, or at least that's how Doctor Beth Remesky, one of the other pediatric surgeons at Cincinnati Children's, has seen this happen. Yeah, we've had a couple unrepaired CDH's valvulize their stomach and need to get fixed more urgently. It's not common, but it's happened. And how did Dr. Ramesky notice it? Well, there were some key things in the presentation. Had a weird looking sort of fixed bubble in the chest that was not able to be decompressed, couldn't advance the repogal. That's the big one, I think, right there. I think a little bit of bloody aspirate from the. Logo can't advance it. Funny looking stomach bubble on the X-ray. OK. So, younger patients, acute presentation, and it's gonna be associated with some sort of anatomic anomaly like a CDH or diaphragmatic eventation. Now, the chronic gastric vulvulus patients. Those are more to do with the laxity of the gastric ligaments, and the stomach has ligamentous attachments basically surrounding the entire stomach from gastrophrenic, gastrosplenic, gastrocolic. And of course. Gastropatic ligament. That usually keeps the stomach in place. But if you, if you don't have those attachments, there are really only two points where the stomach is kept in place, the GE junction and the pylorus. And really, the rotations are gonna be about those points. Now, there are two types. The first one, the first and most common is organoaxial volvulus. If you are listening to this in the state current pediatric surgery app, scroll down under the media player. I'm gonna give you an image so you can kind of visualize this. They describe a line that's drawn on this diagram between the GE junction and the pylorus, and it's spinning around that axis. The greater curvature then sort of flips up and over and becomes more superior than the lesser curvature. Then the second type is mesenteroaxial. Scroll down out of the media player, click on the second image there. This time you can see a line going kind of through the middle portion of the stomach from, you know, the, the lesser curvature to the greater curvature and dividing it in half. Then, and flip the stomach up and over that way, so it's going sort of behind. The stomach and back over it. Now, hypothetically, if you fill the stomach with contrast, how would that look? When the pylorus is at, right next to the GE junction or near the GE junction, and above the body of the stomach. All right, so let's take a minute and just review really quick. So, mostly these are gonna be children in the first year of life, they're gonna present with non-bilious emesis, maybe some gastric distention, maybe they have a history of a CDH or something like that. You're probably gonna have issues passing an NG tube, then you might get plain films and see some significant gastric distention. The next step is to get a contrast study. And what are you gonna see if you, if you try to do like an upper GI in a, in a kid with gastric vulvulus? You would probably see that it doesn't go past the stomach if it makes it into the stomach. Ah, great point from Doctor Ellen and Cisco, research resident at Cincinnati Children's Hospital. If you have the patient swallow or you put dye in a tube that's maybe sitting in the esophagus, what might you see there? Then you might see a classic bird's beak looking appearance. Now, if the contrast is able to slip past the GE junction and get into the stomach, and they have evolveus, then what do you see? The greater curvature would be flipped up. Awesome. Exactly. Now, that's for organoaxial. Now, another weird contrast fighting you might see, the duodenum filling above or superior to the GE junction. Sounds kind of weird, scroll down under the media player. The next image is exactly that. Mesentero axial favulus. Again, this is the sort of pylorus flipping up and over or behind and over the top of the stomach, and then therefore, your pylorus is located all the way up here. Now, let's say hypothetically that you were able to pass the NG tube with the repogo down into the stomach. And then you put contrast in that during your X-ray, what is that gonna look like? Well, that's the next image. Pretty impressive eventation of the left hemi diaphragm. All right, so we talked about the presentation, we talked about the workup, including the uh contrast imaging. Now we have a diagnosis of gastric volvulus. What's next? So let's go to the operating room. What should we do? We would try laparoscopically. Again, Doctor Pinzon Guzman, the first thing is if the stomach is up in the chest, it's to bring it down. OK, so reduce any like hernia or anything like in the chest. And then once you have the stomach in the right place anatomically, how are we gonna keep it there? We would do G tubes, um, to kind of pixy the stomach to the abdominal wall to prevent it from. Twisting again. And then you wanna do a gastropy at at least one other location. The idea being that you wanna fix the stomach in multiple planes to reduce the chance of it volvulizing again in the future. And then you're, you're, you're done. You don't have to do a funduplication like some people do in the adult world. All right, let's do a case. A 37 week gestation age newborn infant undergoes repair of a CDH. At the time of surgery, the stomach is noted to be twisted about its mesentery intraoperatively. What are the management considerations for this child and which procedure, if any, should they undergo? OK. So, twisted about the mesentery. I think that means that this patient has an organoaxial volvulus. So we have to reduce that. Then we have to Pexi it because this is a CDH baby, you know, you're, you're not wrong for placing a G tube, and then you wanna PXI it at another location, right? So it doesn't twist again. Then you want to repair the CDH that's what you're there for in the first place. What did we forget? Also, you always want to check the viability of the stomach. So, right, if this is chronically volvulized or been volvulized for a couple of days, uh, at least looking at the cirrhosa and looking at the blood flow. Because sometimes these patients have kind of like a latent onset. They might have been volvululized for longer than you have known. You just picked it up because of their presentation. All right, let's do another case. A healthy male infant born at term has the sudden onset of non-bilous emesis, abdominal tenderness, and epigastric fullness. The diagnosis of acute valvulus is considered, although the differential remains broad. Discuss the utility of laborator and specific imaging modalities in establishing the diagnosis. All right, so this baby is like sick, sick. So, what are you gonna do in this situation that's different? Well, here's Doctor Chris Pastor. He is the surgical oncology and vascular malformation fellow at Cincinnati Children's. Two good points of IV access. Make sure you're managing uh the ABCs and vascular access. Exactly. So start with the ABCs. We're resuscitating this child first before we go to surgery, right? We don't really know what's going on with them yet. So, like Chris said, you know, we're gonna manage their airway, make sure they're breathing, get two points of IV access, we're gonna send off a full set of labs, and then we got to start to consider what are we gonna do for imaging to start to, you know, get a diagnosis. You know, this gets a uh upper GI every time because you have your, your two big things on your differential. I think most people would probably think this is a malro kid. Uh, just because that's a lot more common than a gastric volvulus. So I think you're going to get a, you're going to call your radiologist in and you're going to get an urgent upper GI and find out what you're dealing with while you're resuscitating this baby. And then once the baby is adequately resuscitated, then, just like the other case, you can go to the operating room, reduce the volvulus, do your gastropies in multiple different planes. Hopefully, this child can have some good outcomes. So, there you have it. Gastricvvulus, a really rare diagnosis, but one that is fairly tested on. Did you like this episode, or did you not like this episode? Well, let us know by leaving a comment, whether you're watching us on YouTube, listening to us on Apple Podcasts, SoundCloud, Stitcher, or Amazon Music. But the best way to listen, to stay current pediatric surgery app. So download it today. It's in the Apple App Store, it's in the Google Play Store, but until then, I'm Rod from Cincinnati Children's, and remember, knowledge should be free.
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