Neonatal organoaxial stomach volvulus

Clinical History

The patient presented with effortless vomiting since birth and was unable to tolerate full feeds.

Imaging Findings

The CXR [Figure 1] and AXR [Figure 2] are unremarkable. There is no diaphragmatic hernia, no distended stomach and no paucity of distal bowel gas to suggest an upper GI obstructive cause for the symptoms (such as duodenal stenosis). The upper GI contrast study [Figures 3 and 4] demonstrates an NG tube with its tip in the stomach and an abnormal orientation of the gastric anatomy, with the greater curve seen to lie above the lesser curve, in keeping with organoaxial volvulus. Note that the pylorus and 1st part of the duodenum are appropriately positioned but appear low-lying in view of the upward displacement of the body of the stomach.

Discussion

Neonatal stomach volvulus is considered a rare entity. [1] There are two types of stomach volvulus, organoaxial and mesenteroaxial, with organoaxial being more common.

The stomach is fixed in position by the gastrocolic, gastrohepatic, gastrophrenic and gastrosplenic ligaments as well as the presence of the gastro-oesophageal junction and pylorus. These act to prevent the stomach from twisting about its axis.

In organoaxial volvulus, the stomach twists about its longitudinal axis so that the greater curvature of the stomach lies above the lesser curvature. In mesenteroaxial volvulus, the stomach twists about an axis perpendicular to the longitudinal axis so that the antrum and pylorus lie superior to and often to the left of the gastro-oesophageal junction.

The presentation of stomach volvulus can be varied, but typically consists of non bilious vomiting, epigastric pain and abdominal distension. It can also present with breathing or, as in this case, feeding difficulties.

It is important to consider stomach volvulus in the differential as without the diagnosis the patient may not improve and, particularly in the case of mesenteroaxial volvulus, may infarct the stomach if the blood supply is compromised by the volved section.

Initial imaging in the neonate should include a chest radiograph to exclude a diaphragmatic hernia and an abdominal radiograph looking for signs of bowel obstruction or duodenal atresia. Ultimately an upper GI contrast study is needed in order to diagnose a stomach volvulus and to exclude malrotation which, although normally associated with bilious vomiting, should be on the differential.

Key imaging findings in organoaxial volvulus include a distended stomach which may lie in a horizontal plane on AXR and/or paucity of distal bowel gas. There may also be elevation of the left hemidiaphragm. The upper GI contrast study will show the greater curvature of the stomach lying above the lesser curvature with a straightened pylorus.

This patient proceeded to laparotomy and the diagnosis was confirmed; the surgeons found absence of the gastrocolic omentum and performed a curative gastropexy, fixing the stomach in position.

Differential Diagnosis List

Final Diagnosis

Organoaxial stomach volvulus

URL:	https://eurorad.org/case/10289
DOI:	10.1594/EURORAD/CASE.10289
ISSN:	1563-4086