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

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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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