Acute intrathoracic gastric volvulus: A rare delayed presentation of congenital diaphragmatic hernia: A case report

INTRODUCTION: Acute intrathoracic gastric volvulus occurs when the stomach undergoes organoaxial rotation in the chest due presence of a diaphragmatic defect. Gastric volvulus associated with congenital diaphragmatic hernia is extremely rare and can be explained as 2 of the 4 ligaments supporting the stomach (gastrophrenic and gastrosplenic) which are connected to the left diaphragm may become elongated or absent. According to the current literature, only 27 pediatric cases have been reported so far. PRESENTATION OF CASE: We describe an 8 years old boy who presented to our emergency department with acute epigastric pain and vomiting. The chest radiograph obtained in the emergency department demonstrated an elevated gastric air-fluid level in the left hemithorax. A computed tomography scan demonstrated a sizable left diaphragmatic defect admitting stomach, small bowel loops and transverse colon with organoaxial gastric volvulus. Emergent laparotomy was done for reduction of the viscera to the abdominal cavity and repair of the diaphragmatic defect. The patient showed an uneventful recovery without experience any pain or difficulty with eating. DISCUSSION: Acute gastric volvulus is a rare pathology defined as an abnormal rotation of the stomach for more than 180° leading to a closed-loop obstruction which may progress to ischemia and strangulation. A plain standing abdominal X-ray and an upper gastrointestinal contrast study are useful for diagnosis, but some authors recommend performing CT or MRI to confirm the diagnosis. The standard treatment for volvulus is open laparotomy with detorsion and anterior gastropexy. CONCLUSION: The presented case highlights congenital diaphragmatic hernia associated with gastric volvulus is a serious condition with very high morbidity and mortality. It should be considered in the differential diagnosis of children with epigastric pain and uncontrolled non bilious vomiting. An upper gastrointestinal contrast study is useful for early diagnosis and surgical treatment should not be delayed awaiting further complementary imaging tests.