A 3-month-old Asian girl presented to the emergency department with a history of recurrent vomiting and passage of dark stools. The vomiting had persisted for 10 days. The vomitus was initially dark and viscous in character. The patient was receiving breast milk. The mother had not experienced infections or noted any soreness or bleeding from her nipples. The patient's birth weight was 3.2 kg and she had not experienced problems in the perinatal or neonatal periods. She had no known allergies and was not on any medications at the time of presentation.
The patient's weight was 5.27 kg. She was afebrile with a heart rate of 128 beats per minute and respiratory rate of 28 per minute. The patient was in no distress. The examining physician found no abnormalities on physical examination. There was no active anal or perianal disease. Digital examination of the rectum yielded hemoccult-positive stool. Laboratory studies were unremarkable. The patient's hemoglobin was 10.6 gm/dl, platelet count 374,000/mm3, and the prothrombin time and APTT were normal. Chest(Fig. 1) and abdominal radiographs were obtained the diagnosis:
- Diaphragmatic hernia
- Intrathoracic gastric volvulus
- Esophageal duplication cyst
- Malignant chest tumor
- Lobar pneumonia
Answer: A left lateral decubitis film revealed a large air fluid level in the right hemithorax with an absence of the gastric bubble in the left upper quadrant. Decubitis chest films were subsequently obtained which revealed a right, posterior basilar mass with an air fluid level. Again, the gastric bubble was not clearly identified below the diaphragm. A nasogastric tube was placed and omnipaque was infused (Fig. 2A and 2B). The nasogastric tube and the stomach were identified in the right lower hemithorax. The esophagus appeared “foreshortened.” The proximal descending duodenum was thought to be narrowed and was taken in the region of the diaphragmatic hiatus. The patient was taken to surgery where she was found to have a gastric volvulus in a large paraesophageal hiatal hernia.
Comment: Gastric volvulus most commonly occurs in newborn infants but may occur in later childhood, especially in the mentally impaired. It may occur in association with a diaphragmatic hernia or with a paraesophageal hiatal hernia. The stomach twists on either its long access (organoaxial) or on its mesentery (mesenteroaxial). Gangrene and perforation may develop when the diagnosis is delayed. The clinical picture can be acute or chronic and usually includes vomiting and respiratory distress. The current patient suffered with vomiting but it was the gastrointestinal bleeding that brought the patient to medical attention. She was in no respiratory distress. Contrast studies often reveal a “bird's beak” deformity just below diaphragm as was seen in this case. Management is surgical.