Neonatal Gastric Volvulus with Dr. Jason Frischer

Published: 2022-06-14

15 Views

0 Likes

0 Shares

0 Comments

Grand Rounds

View profile →

Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Rod Gerardo — host
Jason Frischer — guest
Beth Remesky — guest
Ellen Cisco — guest
Carolina Pinzon Guzman — guest
Chris Pastor — guest

Chapters

0:00Introduction and App Promotion — Host introduces the episode and promotes the Stay Current Pediatric Surgery app for visual content and supplementary resources.
0:42Epidemiology and Associated Anomalies — Discussion of gastric volvulus rarity, associations with CDH (17%) and diaphragmatic eventration (25%), and age distribution with 60% occurring in the first year of life.
1:58Acute vs Chronic Presentation and Anatomic Basis — Differentiation between acute presentation in younger infants with anatomic anomalies versus chronic presentation related to laxity of gastric ligaments. Discussion of gastric fixation points at GE junction and pylorus.
3:43Types of Gastric Volvulus — Detailed explanation of organoaxial volvulus (rotation around GE junction-pylorus axis with greater curvature flipping superior) and mesenteroaxial volvulus (rotation perpendicular to long axis).
4:58Clinical Presentation and Diagnostic Imaging — Review of typical presentation (non-bilious emesis, gastric distention, inability to pass NG tube), plain film findings, and contrast study findings including bird's beak appearance and duodenum filling above GE junction.
7:05Surgical Management Principles — Discussion of laparoscopic approach, reduction of herniated stomach, gastropexy with G-tube placement, and additional gastropexy in multiple planes to prevent recurrence.
7:53Case 1: CDH with Intraoperative Volvulus — Case discussion of 37-week neonate undergoing CDH repair with intraoperatively discovered gastric volvulus, emphasizing need to assess viability, reduce volvulus, perform gastropexy, and repair CDH.
9:04Case 2: Acute Presentation in Healthy Term Infant — Case of previously healthy term infant with sudden onset symptoms requiring resuscitation, differential diagnosis including malrotation, and urgent upper GI study followed by surgical intervention.
10:44Closing Remarks — Summary of gastric volvulus as rare but testable diagnosis, with promotion of podcast platforms and app.

Key claims

1:18Gastric volvulus is associated with CDH about 17% of the time — Rod Gerardo
1:18Gastric volvulus is associated with eventration of the diaphragm about 25% of the time — Rod Gerardo
1:3360% of gastric volvulus cases happen in the first year of life in the pediatric population — Jason Frischer
1:33About 21% of pediatric gastric volvulus cases occur in the first month of life — Jason Frischer
1:58Acute gastric volvulus in young infants (around 4 months old) is more likely than chronic presentation — Jason Frischer
2:13Acute gastric volvulus is usually due to anatomic problems like CDH — Rod Gerardo
2:24Unrepaired CDH patients can volvulize their stomach and need urgent surgical correction — Beth Remesky
2:38Key presentation findings include inability to advance the NG tube, bloody aspirate from the NG tube, and abnormal-looking stomach bubble on X-ray — Beth Remesky
3:10Chronic gastric volvulus is related to laxity of the gastric ligaments — Jason Frischer
3:10The stomach has ligamentous attachments including gastrophrenic, gastrosplenic, gastrocolic, and gastropatic ligaments — Jason Frischer
3:27Without ligamentous attachments, the stomach is only fixed at two points: the GE junction and the pylorus — Rod Gerardo
3:43Organoaxial volvulus is the first and most common type of gastric volvulus — Jason Frischer
3:55In organoaxial volvulus, the stomach rotates around an axis between the GE junction and pylorus, with the greater curvature flipping superior to the lesser curvature — Jason Frischer
4:18In mesenteroaxial volvulus, rotation occurs around a line through the middle of the stomach from lesser to greater curvature — Jason Frischer
4:46In mesenteroaxial volvulus with contrast, the pylorus appears next to or near the GE junction and above the body of the stomach — Jason Frischer
4:58Typical presentation includes non-bilious emesis, gastric distention, and possible history of CDH — Rod Gerardo
5:10Patients with gastric volvulus typically have issues with NG tube passage — Rod Gerardo
5:10Plain films may show significant gastric distention in gastric volvulus — Rod Gerardo
5:21Contrast study is the next diagnostic step after plain films — Rod Gerardo
5:32On upper GI, contrast may not pass beyond the stomach or may not make it into the stomach in gastric volvulus — Ellen Cisco
5:49A classic bird's beak appearance may be seen when contrast is in the esophagus or at the GE junction — Rod Gerardo
6:02If contrast enters the stomach in organoaxial volvulus, the greater curvature appears flipped up — Ellen Cisco
6:08In mesenteroaxial volvulus, the duodenum may fill above or superior to the GE junction — Rod Gerardo
7:09Laparoscopic approach should be attempted for surgical management — Carolina Pinzon Guzman
7:11If the stomach is herniated into the chest, it must be reduced back into the abdomen — Carolina Pinzon Guzman
7:26G-tube placement is used to pexy the stomach to the abdominal wall to prevent recurrent twisting — Carolina Pinzon Guzman
7:34Gastropexy should be performed at at least one additional location beyond the G-tube site — Rod Gerardo
7:37The goal of multiple gastropexy sites is to fix the stomach in multiple planes to reduce recurrence risk — Rod Gerardo
7:47Fundoplication is not required in pediatric gastric volvulus repair, unlike in adult practice — Rod Gerardo
8:40Viability of the stomach must always be assessed intraoperatively, especially if chronically volvulized — Jason Frischer
8:53Patients may have latent onset with volvulus present longer than clinically apparent — Rod Gerardo
9:38In acute presentation with sick infant, initial management focuses on ABCs and obtaining two points of IV access — Chris Pastor
9:49Full set of labs should be sent during resuscitation — Rod Gerardo
10:14Malrotation is more common than gastric volvulus and should be high on the differential for acute presentation — Chris Pastor
10:20Urgent upper GI study should be obtained while resuscitating the patient to establish diagnosis — Chris Pastor

Cases discussed

7:5337-week gestation neonate undergoing CDH repair with intraoperatively discovered gastric volvulus twisted about its mesentery
9:04Previously healthy term male infant with sudden onset of non-bilious emesis, abdominal tenderness, and epigastric fullness

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Gastric Volvulus in Neonates: Recognition, Classification, and Surgical Fixation

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Teaching arc · AI-written, human-reviewed

Age Dictates Mechanism and Presentation

The first decision point is recognizing that gastric volvulus in infants follows two distinct patterns based on age and underlying anatomy 1:33 1:33. Sixty percent of cases occur in the first year of life, with 21% presenting in the first month 1:33 1:33. Acute presentations in young infants—typically around four months—are more common than chronic presentations and signal an anatomic problem 1:58. These acute cases associate with congenital diaphragmatic hernia 17% of the time and diaphragmatic eventration 25% of the time 1:18 1:18. The infant who cannot tolerate an NG tube, has bloody aspirate, and shows an abnormal stomach bubble on plain film likely has an acute volvulus tied to a structural defect 2:38. Chronic presentations, by contrast, relate to laxity of the gastric ligaments—the gastrophrenic, gastrosplenic, gastrocolic, and gastropatic attachments that normally anchor the stomach 3:10 3:10. Without these, the stomach is fixed only at the GE junction and pylorus, creating two potential axes of rotation 3:27.

Classification Determines What You See on Contrast

Organoaxial volvulus is the most common type 3:43. The stomach rotates around a line connecting the GE junction to the pylorus, flipping the greater curvature superior to the lesser curvature 3:55. On upper GI, if contrast enters the stomach, the greater curvature appears flipped up 6:02. Mesenteroaxial volvulus rotates perpendicular to the long axis—through a line from lesser to greater curvature 4:18. The pylorus ends up adjacent to or above the GE junction, and the duodenum may fill superior to the GE junction 4:46 6:08. Contrast studies are diagnostic: if the study shows a bird's beak at the GE junction, contrast that will not pass into the stomach, or anatomic relationships that violate normal gastric orientation, the diagnosis is made 5:32 5:49. Plain films showing significant gastric distention and inability to advance an NG tube should prompt immediate contrast imaging 5:10 5:10 5:21.

Surgical Fixation Requires Multiple Points of Attachment

The laparoscopic approach is preferred 7:09. If the stomach has herniated into the chest, reduce it first 7:11. G-tube placement serves dual purposes: decompression and gastropexy to the abdominal wall 7:26. But a single point of fixation is insufficient—gastropexy must be performed at at least one additional site 7:34. The goal is to fix the stomach in multiple planes to prevent recurrent torsion 7:37. Fundoplication is not required in pediatric patients, unlike adult practice 7:47. The critical intraoperative assessment is stomach viability 8:40. Patients may have had volvulus present longer than the clinical presentation suggests—a latent onset where the stomach has been compromised for days before symptoms became obvious 8:53. Inspect the serosa and assess blood flow before completing the repair.

Malrotation Remains the More Likely Diagnosis in Acute Presentation

When a previously healthy term infant presents with sudden non-bilious emesis and abdominal findings, gastric volvulus must be considered, but malrotation is statistically more common and should be higher on the differential 10:14. Initial management focuses on ABCs and obtaining two points of IV access 9:38. Send a full set of labs during resuscitation 9:49. The diagnostic study is an urgent upper GI performed while resuscitation continues 10:20. The radiologist must distinguish between malrotation with midgut volvulus and gastric volvulus—both can present with inability to pass contrast beyond the stomach, but the anatomic relationships on fluoroscopy will differ. Do not delay imaging to complete resuscitation; the study informs whether the patient needs emergent surgery and what operation to perform.

Takeaways from this story

Acute gastric volvulus in infants under 4 months signals anatomic defect—17% CDH, 25% diaphragmatic eventration
Gastropexy must fix stomach in multiple planes—G-tube alone insufficient, requires second fixation site
Assess stomach viability intraoperatively—volvulus may predate clinical presentation by days
Malrotation more common than gastric volvulus in acute presentation—urgent upper GI distinguishes

Topic overview

A clinical discussion of neonatal and infant gastric volvulus led by Dr. Jason Frischer and Dr. Rod Gerardo at Cincinnati Children's. The discussion covers the epidemiology (60% occur in the first year of life), anatomic associations (17% with CDH, 25% with diaphragmatic eventration), two rotation types (organoaxial and mesenteroaxial), diagnostic imaging findings including bird's beak appearance and contrast studies, and surgical management consisting of reduction, gastropexy in multiple planes, and G-tube placement. Two clinical cases illustrate acute presentation in a CDH repair and a previously healthy term infant with sudden onset symptoms.

Key takeaways

60% of gastric volvulus occurs in first year; 17% associate with CDH, 25% with diaphragmatic eventration (1:18)
Classic triad: inability to pass NG, bloody NG aspirate, abnormal gastric bubble on X-ray. Confirm with upper GI showing bird's beak (2:38)
Surgical repair requires reduction, G-tube placement PLUS additional gastropexy site to fix stomach in multiple planes (7:26)
Fundoplication not required in pediatric cases, unlike adult practice (7:47)
Always assess stomach viability intraoperatively; latent onset means volvulus may be present longer than clinically apparent (8:40)

Keywords

gastric volvulus congenital diaphragmatic hernia diaphragmatic eventration organoaxial volvulus mesenteroaxial volvulus malrotation upper GI study gastropexy G-tube placement CDH repair laparoscopy NG tube placement Cincinnati Children's Hospital Medical Center University of Michigan

Hashtags

#PediatricSurgery #GastricVolvulus #NeonatalEmergency #CDH

Transcript

Click "Show Transcript" to view the full text (10705 characters)

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.

Comments

Loading comments...