P3D254: Common Gastrointestinal Symptoms with a 'Twist'- chronic Gastric Volvulus in a Pediatric Patient

Introduction: Gastric volvulus is a rare condition with mortality of up to 30-50% in acute cases. Only 581 pediatric cases were reported between 1929 and 2007, most in patients less than one years old. Diagnosis is often delayed due to vague symptoms that mimic more common conditions, such as viral gastroenteritis. The chronic variant can be particularly difficult to diagnose as it often causes more mild, intermittent symptoms, and often doesn’t conform to Borchardt’s triad of acute volvulus- retching, epigastric swelling, and the inability to pass a nasogastric tube (NG tube).

Case Description: A nonverbal, developmentally delayed 13-year-old female with Pitt-Hopkins syndrome, failure to thrive (BMI 15), and chronic constipation began to also experience sporadic episodes of mild emesis and agitation. Gastroenterology performed an upper endoscopy, which was normal. However, four days post-endoscopy, she presented to the ED with acutely worsened abdominal pain and emesis. Upon admission for observation, hydration, and work-up, her abdomen was soft, not overtly tender to palpation and appeared non-distended. Shortly after admission, her agitation progressed and a KUB displayed an extensively distended stomach (Figure 1a), with an otherwise non-obstructive bowel gas pattern. An NG tube was successfully passed to initiate gastric decompression (Figure 1b), but the film showed possible gastric outlet obstruction or proximal duodenal obstruction. A subsequent upper GI series revealed abnormal gastric antrum and body positioning, concerning for mesenteroaxial gastric volvulus (Figure 2). A review of her films obtained over several years showed occasional marked gastric distension, suspicious for chronic intermittent gastric volvulus. Pediatric surgery therefore performed a gastropexy with gastrostomy tube placement in order to prevent volvulus recurrence. Post-operatively, her emesis resolved and abdominal pain diminished. Four months later, the patient had no further episodes of fussiness and emesis with good weight gain.

Discussion: Though rare, chronic gastric volvulus should be considered in pediatric patients with poor growth, decreased appetite, nausea, and intermittent abdominal pain, even if an NG tube can be passed or distal bowel gas is present. While mortality in chronic volvulus is much lower than acute volvulus (less than half), roughly 1 in 8 chronic volvulus patients will develop an acute episode. An abdominal Xray may reveal gastric distension when gastric volvulus is suspected, but an upper GI series remains the diagnostic gold standard and can inform surgical management.

Conclusion: This case demonstrates a patient having non-classic symptoms of an uncommon diagnosis. The patient’s non-verbal status, pre-existing chronic constipation, and lack of known association between volvulus and Pitt Hopkins syndrome created additional diagnostic challenges in recognizing her chronic gastric volvulus. Once identified, successful NG tube decompression and surgical intervention were curative. Timely consideration of this rare condition in pediatric patients, with appropriate imaging and intervention may prevent mortality or significant morbidity, including gastric perforation.