Volvulus of the stomach

VOLVULUS OF THE STOMACH JOHN P . WEST, M .D . AND VAUN T. FLOYD, M .D . New York, New York

V

OLVULUS of the stomach which results in obstruction of the esophageal and duodenal orifices is a rapidly progressive

severe pain . The abdomen becomes distended and although nausea is constant, attempts to vomit are unsuccessful except for the return of those fluids which have been retained in the esophagus . Roentgen examination reveals a distended abdominal viscus and a swallow of barium suffices to demonstrate obstruction at the lower end of the esophagus . The case herein reported is the only one recorded at St . Luke's Hospital during the past twenty years . It also appears to be unique in that the patient had a large diaphragmatic hernia, which often contained a major portion of the stomach, but at operation the distended and twisted stomach was intra-abdominal except for a small portion of its fundus . The rarity of this condition warrants re-emphasis of the clinical features which may lead to early diagnosis and proper treatment . CASE REPORT

Roentgenogram following barium meal showing that most of stomach is above the diaphragm . FIG . I .

and fatal condition unless corrected by early operation . The more common type of gastric volvulus is due to incarceration and torsion of the stomach within a diaphragmatic hernia .' -5 Symptoms of acute high intestinal obstruction develop in patients with this type of volvulus . There is no abdominal distention and the significant physical and roentgen signs indicate fluid and usually some air in the chest . A less common form of volvulus is due to rotation of the intra-abdominal stomachs -9 Patients with this type of volvulus complain of

Mrs . E . T ., age sixty-six, was first seen in the medical clinic of St . Luke's Hospital in 1945 . At that time she gave a history of epigastric distress and occasional bouts of vomiting which, however, had not interfered with nutrition or ability to work . A roentgenogram of the chest showed a gas shadow above the diaphragm and to the right of the midline . Subsequent barium studies confirmed the diagnosis of a diaphragmatic hernia containing part of the stomach . (Figs . i and 2 .) Repair of the hernia was advised but the patient thought that her symptoms were not severe enough to warrant operation and she continued her work as a hospital maid . She was admitted to the hospital on March 30, 1951, complaining of crampy abdominal pain, distention and obstipation of two days' duration . Although nauseated, the patient had been unable to vomit . At the time of admission she appeared dehydrated and acutely ill . The abdomen was markedly distended, respirations were shallow and definite cyanosis was present . Blood pressure was 96/78, pulse i io and tem112

American Journal of Surgery



West, Floyd-Volvulus of the Stomach

1 13

GREATER CURVATURE

LESSER CURVATURE

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I Ill DUODENUM

Ftc . 2 . Drawing shows the parahiatus hernia containing stomach as in Figure i .

FIG. 4 . Roentgenogram with patient standing . Three

fluid levels are seen and again the barium remains in the lower esophagus .

FIG . 3 . Roentgenogram with patient in supine position after swallowing barium . A markedly distended viscus is seen with a small amount of barium in esophagus .

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West, Floyd-Volvulus of the Stomach

perature 103.6°F. Roentgenograms showed (Figs. 3 and 4) a large distended viscus filling the upper abdomen . Fluid levels were noted on the films taken with the patient in an upright position and confirmed the impression that

way that the lesser curvature tended to present anteriorly . Repeat roentgen studies two months later revealed that the stomach was again in the hiatus hernia . Although she had no symptoms,

Fic. 5 . Drawing to illustrate volvulus of the stomach as found at operation .

only a small part of the stomach was above the diaphragm . Attempts to pass a gastric tube were unsuccessful and after a short period devoted to administration of intravenous fluids, the patient was operated upon . She was found to have an enormously dilated stomach which had rotated in such a way that the pylorus was under the left diaphragm and the fundus was rotated to the right with a major portion of the posterior wall presenting anteriorly . The pyloric and esophageal orifices were obstructed . (Fig . 5.) The stomach was emptied by means of a trochar and returned to its normal intraabdominal position . Improvement was rapid and the patient's hospital course was uncomplicated . Barium studies prior to discharge showed the stomach to be below the diaphragm but partially rotated on its long axis in such a

the patient at this time agreed to have the hernia repaired . This was done on June 23, 1951, through a combined thoraco-abdominal incision . The hernia was found to be of the parahiatal type with the defect in the diaphragm to the right of the esophageal hiatus . The sac of the hernia extended up into the posterior mediastinum for an estimated distance of 16 cm . The stomach was withdrawn without difficulty and the neck of the sac divided and closed without excision . The defect in the diaphragm was closed by interrupted sutures of silk . Again the postoperative course was uncomplicated and the patient has remained free of all gastric symptoms . Roentgenograms one year later showed no evidence of recurrence of the hernia . Some rotation of the stomach has persisted . American Journal of Surgery



West, Floyd-Volvulus of the Stomach CONCLUSIONS I . Acute epigastric pain, abdominal distention and the inability to vomit gastric contents are suggestive of volvulus of the stomach . 2 . The diagnosis may he confirmed by roentgenography . 3 . Immediate surgical relief of the obstructing volvulus is imperative . 4 . Associated defects, such as a diaphragmatic hernia, should he corrected at a later date . REFERENCES 1 . GIBSON, F . S. Diagnosis of diaphragmatic hernia

with acute obstruction . J . A . Al. A ., 93 : 17191724, 1929 .

2 . TRUESDALE, P. F . Hernia of the diaphragm in children . J. A . N1. A ., 93 : 1538 - 1544. 1929 . 3 . CARTER, N . B . and GUISEFFI, J . Strangulated diaphragmatic hernia . Ann. Stag ., 128 : 210-225, 1948 . 4. HARRINGTON, S . W. Various types of diaphragmatic hernia treated surgically : report of 431) i. cases . Surg., Gynec. e, Obsl ., 86 : 735 - 755 . 1948SWEET, R . H . Esophageal hiatus hernia of the diaphragm . Ann . Surg ., 135 : 1-13. 1952 . 6 . KERR, H . H . Volvulus of the Stomach . Ann . Surg., 56 : 697-709 . 1912 . 7 . TnoRER, M . Acute total volvulus of the stomach, J . A . 'J. A ., 8, : 636-640, 1923 . 8 . BUCHANAN, J . Volvulus of the stomach . Brit . J . Surg ., 18 :99-112, 1930Q . RUSSELL, J . Y . 6Y' . Volvulus of the stomach . Brit . .1 . Surg ., 38 : 17-20, 1950 .

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CHILDREN born with spina bifida and rectal incontinence can be helped by construction of a substitute sphincter muscle . Pickrell and colleagues obtained good results in several such children by transplanting the gracilis muscle with its intact blood and nerve supply . This forms an excellent voluntary sphincter for the rectum although it is not an automatic one . At any rate, satisfactory rectal continence results . (Richard A . Leonardo, M .D .)

July, 1953

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