Gastric volvolus with wandering spleen and pancreatic torsion in a 5years old girl

A five years old girl was taken to our emergency department with a history of few hours of acute abdominal pain in the upper quadrants and non biliary vomiting, followed by retching. The patient was afebrile, with a huge distended abdomen, without tenderness. The rest of the physical examination was unremarkable. A nasogastric tube was passed with some difficulty, a venous access was secured and blood tests were taken: WBC were 12.050U/uL, RCP was 8,8mg/L, pancreatic amylase were elevated at 430U/L. Serum electrolytes, liver and renal function, haemostasis were normal. An abdominal ultrasound (US) revealed a spleen localized in the right flank, below the liver and an abdominal computed tomography (CT) scan was performed (Figures 1-2). The exam showed a well vascularised spleen in the right flank below the liver, a dislocation to the right of the pancreatic tail and body and a huge distended stomach with a the nasogastric tube inside. The diagnosis was gastric volvolus associated with wandering spleen and pancreatic torsion. Fluid resuscitation and antibiotic therapy were started. The girl spontaneously lied on the left flank as her preferred decubitus and after a while the spleen was palpated not in the right flank but in mesogastrium. She was taken to the operatory theatre as soon as fluid resuscitation was secured an emergency and an open laparotomy was performed. A gastric mesenteroaxial volvolus was found associated to uncomplete torsion of the spleen and pancreatic tail. There were no legaments of fixation between spleen and stomach, nor between spleen and kidney, nor between spleen and abdominal wall. There were no signs of severe gastric ischemia. The stomach was derotated and the spleen restored to its normal position since the tissue was completely viable. An omental patch associated to splenopexy was performed to keep the spleen in place and a diaphragmatic and anterior gastropexy was performed. The recovery was uneventful, the amylases returned to normal values within two days and the girl was discharged on postoperative day 4th. At 24months the girl is asymptomatic and a follow-up ultrasound revealed a spleen and stomach in its normal position.