ORIGINAL ARTICLE

Early diagnostic clues in neonatal chronic gastric volvulus

Levent Duman • Mustafa Cagri Savas •

Behcet Ilker Buyukyavuz • Mustafa Akcam •

Gonca Sandal • Aykut Recep Aktas

Received: 16 January 2013 / Accepted: 30 April 2013 / Published online: 9 May 2013

� Japan Radiological Society 2013

Abstract

Purpose Neonatal gastric volvulus (GV) is a rare clinical

entity with a challenging diagnosis. In this study, we aimed

to identify clinical and radiological findings to aid in early

diagnosis in neonatal GV.

Materials and methods The medical records of all neo-

nates with GV were retrospectively reviewed. Diagnosis

was made based on clinical findings and radiological

images, and was documented by an upper gastrointestinal

(UGI) contrast study.

Results A total of eight neonates were included in the

study. The most common clinical presentations were non-

bilious vomiting and epigastric distention. The findings

highly suggestive for GV in plain radiographs include

gastric double bubble, abnormal gastric distention despite a

nasogastric tube, distended stomach lying in a horizontal

plane and an air-fluid level in the epigastrium.

Conclusion GV should be suspected in any newborn with

non-bilious vomiting and epigastric distention. It is also

important to focus on the clues in the plain radiographs.

Gastric double bubble, abnormal gastric distention despite

a nasogastric tube, distended stomach lying in a horizontal

plane and an air-fluid level in the epigastrium must alert the

physicians to the possibility of GV.

Keywords Gastric volvulus � Neonate � Diagnosis

Introduction

Gastric volvulus (GV) is a rare clinical entity in the neonatal

period [1]. Because clinical and radiological findings are

non-specific, the diagnosis is not always easy. Thus, we

planned a retrospective clinical study to identify clinical and

radiological findings to aid in early diagnosis in neonatal GV.

Materials and methods

The study was approved by the Institutional Review Board

(IRB no.: B.30.2.SDU.0.20.05.00-50-2682). The medical

records of the all neonates with GV were retrospectively

reviewed with respect to gender, clinical presentations,

imaging findings and treatment modalities. The patients

presenting after the neonatal period were excluded from the

study. Images included abdominal plain radiographs and

upper gastrointestinal (UGI) contrast studies. All of the

abdominal plain radiographs of each patient were reviewed

by an experienced radiologist for findings highly sugges-

tive of the diagnosis. The diagnosis was confirmed by UGI

contrast studies in all cases.

Results

Between January 2010 and August 2012, a total of 520

neonates had been hospitalized in our neonatal intensive

L. Duman (&) � M. C. Savas � B. I. Buyukyavuz

Department of Pediatric Surgery, Suleyman Demirel University

School of Medicine, 32260 Isparta, Turkey

e-mail: leduman@gmail.com

M. Akcam � G. Sandal

Department of Pediatrics, Suleyman Demirel University School

of Medicine, 32260 Isparta, Turkey

A. R. Aktas

Department of Radiology, Suleyman Demirel University School

of Medicine, 32260 Isparta, Turkey

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Jpn J Radiol (2013) 31:401–404

DOI 10.1007/s11604-013-0213-9

Table 1 Clinical features of the neonates with gastric volvulus

Case Sex Weight (g) Presenting symptoms Type of volvulus

1 F 2,950 Vomiting, epigastric distention OA

2 F 1,230 Vomiting, epigastric distention OA

3 F 2,700 Vomiting, epigastric distention OA

4 M 2,870 Vomiting OA

5 M 2,520 Vomiting OA

6 F 2,750 Feeding intolerance, epigastric distention OA

7 M 2,010 Feeding intolerance, epigastric distention OA

8 F 2,180 Vomiting, epigastric distention OA

F female, M male, OA organoaxial

Fig. 1 a Plain abdominal radiograph showing double gastric bubble (asterisk shows one bubble, arrow shows the other). b UGI contrast study

demonstrating organoaxial gastric volvulus, c the schematic view

Fig. 2 a Plain abdominal

radiograph showing abnormal

gastric distention despite a

nasogastric tube; b the

schematic view

402 Jpn J Radiol (2013) 31:401–404

123

care unit. Among these, eight (1.5 %) neonates were

diagnosed as having GV. The clinical features of our series

are presented in Table 1. There were three males and five

females. The average age and weight were 6.7 days and

2,400 g, respectively. Their presenting symptoms were

recurrent non-bilious vomiting (6 patients), epigastric dis-

tention (6 patients) and feeding intolerance (2 patients).

The average length of symptoms until the diagnosis was

5.5 days (range 2 to 12 days). Some of the earliest findings

in the plain abdominal radiographs suggesting GV include

gastric double bubble, which refers to the appearance of

two overlapping large spherical bubbles in the epigastrium,

in 6 patients (Fig. 1), abnormal gastric distention despite a

nasogastric tube in seven patients (Fig. 2), distended

stomach lying in a horizontal plane in six patients (Fig. 3)

and an air-fluid level in the epigastrium in three patients

(Fig. 4). UGI contrast studies showed an organoaxial type

of GV in all cases, and there was no obstruction to the

passage of contrast agent into the duodenum. Three of the

patients were treated with conservative therapy. Five non-

responsive patients underwent surgery. None of the

operated patients had an associated diaphragmatic abnor-

mality or predisposing cause.

Discussion

GV is a rare condition in children. Early presentation in the

neonatal period accounts for 26 % of all cases [1].

Although the etiology of neonatal GV is still not fully

understood, some factors such as laxity or congenital

absence of one or more supporting gastric ligaments,

abnormal gastric distention, wandering spleen, congenital

bands and diaphragmatic abnormalities have all been

reported to be responsible [2–6]. In the present study, no

predisposing causes were identified in the operated

patients. Possible laxity of ligamentous attachments in the

neonatal period and the over-distended transverse colon

with gas may have led to volvulus.

There are several classifications of GV. It is classified into

acute and chronic in terms of onset. Acute GV is a surgical

emergency. In the chronic form, the symptoms are frequently

Fig. 3 a Plain abdominal

radiograph shows distended

stomach lying in a horizontal

plane; b the schematic view

Fig. 4 a Plain abdominal

radiograph showing gastric

distention with an air-fluid level

in the epigastrium; b the

schematic view

Jpn J Radiol (2013) 31:401–404 403

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non-specific [7]. Organoaxial GV is the more commonly

diagnosed form in chronic cases [2]. None of the patients had

acute onset, and all had the organoaxial type in our series. In

this respect, neonatal GV can be classified into chronic type,

in which the clinical symptoms depend on the degree of

rotation and gastric outlet obstruction. The most common

clinical signs and symptoms include non-bilious vomiting,

epigastric distention, feeding difficulties and growth failure.

Non-bilious vomiting and epigastric distention were the

main symptoms in our series. Feeding problems without

vomiting can also be a presenting symptom. Nevertheless,

these clinical features of neonatal GV are nonspecific for the

diagnosis and may resemble other conditions.

The diagnosis of neonatal GV represents a clinical chal-

lenge. Several reports have outlined missed or delayed diag-

nosis due to nonspecific clinical symptoms, and a delay in

diagnosis can be problematic [7–11]. Another problem is

unawareness of this diagnosis by physicians, and an incidental

diagnosis of GV is common on an UGI contrast study per-

formed for other more common conditions such as reflux.

Although UGI contrast study is still considered the gold stan-

dard for the diagnosis of GV, it is essential to focus on the clues

in the plain radiographs for early diagnosis. Some clues in the

plain radiographs pointing out neonatal GV include gastric

double bubble, abnormal gastric distention despite a nasogas-

tric tube, a distended stomach lying in a horizontal plane and an

air-fluid level in the epigastrium. All neonates in our series had

organoaxial GV. This type of volvulus causes the greater cur-

vature of the stomach to fold superior to the lesser curvature,

which results in the formation of two overlapping gastric

chambers. The term gastric double bubble depicts the air

trapped in these gastric chambers, which creates the appearance

of two overlapping large spherical bubbles in the epigastrium

visible on X-ray. Normally, the nasogastric tube must com-

pletely remove the air in a distended stomach. In the case of GV,

the nasogastric tube only discharges gas bubbles into the

proximal gastric chamber, and the gas in the folded distal part

remains. This situation results in abnormal gastric distention

despite the nasogastric tube. In organoaxial GV, the stomach

rotates around its longitudinal axis and tends to lie in a hori-

zontal plane, which is another early diagnostic clue in the plain

radiographs. An air-fluid level in the epigastrium can also be

seen in some cases because of partial gastric obstruction. Some

of these findings have been previously reported in acute cases

[2, 8, 10, 12–15]. However, all patients in our series had chronic

onset, in which the diagnosis is not always easy to make.

Although these radiological findings are highly suggestive of

neonatal GV, the diagnosis must always be confirmed with an

UGI contrast study before treatment.

In conclusion, GV should be suspected in any newborn

with non-bilious vomiting and epigastric distention. It is

also important to focus on the clues in the radiographs.

Gastric double bubble, abnormal gastric distention despite

a nasogastric tube, a distended stomach lying in a hori-

zontal plane and an air-fluid level in the epigastrium in the

plain abdominal radiographs should alert physicians to the

possibility of GV. However, the diagnosis must be con-

firmed with an UGI contrast study.

Conflict of interest None.

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