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Vomiting in a 2-Year-Old With A Twist: Undiagnosed Gastric Volvulus

Bhesania, Natalie*,†,‡; Anani, Anthony*,†,‡; Ochs, Heidi*,†,‡; Okwu, Vera*,†,‡; Magnuson, David*,†,‡; Kay, Marsha*,†,‡

Journal of Pediatric Gastroenterology and Nutrition: April 2017 - Volume 64 - Issue 4 - p e106
doi: 10.1097/MPG.0000000000000794
Image of the Month

*Department of Pediatrics

Department of Pediatric Gastroenterology

Department of Pediatric Surgery, Cleveland Clinic Children's, Cleveland, OH.

Address correspondence and reprint requests to Anthony Anani, MD, MBA, MPH, Cleveland Clinic, Cleveland, 9500 Euclid Ave, Cleveland, OH 44195 (e-mail:

Submissions for the Image of the Month should include high-quality TIF endoscopic images of unusual or informative findings. In addition, 1 or 2 other associated photographs, such as radiological or pathological images, can be submitted. A brief description of no more than 200 words should accompany the images. Submissions are to be made online at, and will undergo peer review by members of the NASPGHAN Endoscopy and Procedures Committee, as well as by the Journal.

The authors report no conflicts of interest.

A 2-year-old girl with a 5-month history of early satiety, dyspepsia, and intermittent bilious emesis presented to the emergency room with a day's history of persistent vomiting and abdominal pain. Vital signs were stable but physical examination revealed abdominal distention with absent bowel sounds. She had mild leukocytosis and imaging revealed the findings above.



Image 1: Chest x-ray: gastric distention with an air-filled loop of bowel in the thoracic cavity.



Image 2: Computed tomograph coronal view of abdomen/chest: diaphragmatic hernia with stomach (arrow) above right hemidiaphragm in horizontal plane, consistent with organoaxial gastric volvulus.

An emergent surgical consultation was obtained and exploratory laparotomy revealed a giant congenital posterior hiatal hernia, chronic incarcerated stomach with organoaxial volvulus, and massive perihiatal inflammation with fibrosis. Hiatal hernia was repaired primarily and buttressed with biological prosthetic patch (alloderm). She also underwent a Thal fundoplication to minimize postoperative gastroesophageal reflux disease as a result of impaired lower esophageal sphincter function.

We present a case of acute organoaxial gastric volvulus, secondary to congenital hiatal hernia in a 2-year-old girl, with a complicated repair because of chronic fibrosis and scarring that most likely had been occurring over time. Our case adds to the literature on gastric volvulus, which is rare in the pediatric population and can be a life-threatening emergency. An upper gastrointestinal series should be considered in a child with persistent vomiting of unclear etiology before the development of acute complications as seen in this case (1-6).

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© 2017 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,