A patient was 20 days-old male who was admitted complaining respiratory distress, cyanotic facies and projectile vomiting for 5 days.
The symptoms and signs had developed progressively since he was 15 days old. At time of admission, physical examination revealed a normally developed with well nourished but moderate irritability at rest and cyanotic facies and dry texture.
His weight 3,110gm, the pulse was 164/min., and respiratory rate was 70/min, and 37℃ of body temperature.
On auscultation the breathing sound was diminished on the left lower chest and shifted of cardiac beat to the right side.
No hepatomegaly, peristalsis and other abnormality was demonstrated. Nothing was found to be abnormal in urinalysis, hematology and ECG. Plain chest x-ray showed a high left diaphragm, hazy density of the left lower lung field and displacement of mediastinum to the right side. Barium studies (Fig. 2) revealed a double contour of the stomach, high position of pylorus and pyloric obstruction.
In March, 1971, surgical reair was performed through a left posteriorlateral thoracotomy and midline incision of abdomen, and resection of the membranous diaphragm and suturing of the muscular components and gastropexy. In this case, it was felt that localized defect with simple placation of the thinned diaphragm and stomach appeared larger than normal and this could be condusive to volvulus and pyloric obstruction.
The post-operative course had been uneventful for 2 weeks when he was noted a normal life activity. Following operation, roentgenographic demonstration of (Fig. 5) improvement in position of the left diaphragm and aeration of the overlying lung.
Eventration of the diaphragm with volvulus of the stomach is relatively uncommon. The definite etiology is still not known. Furthermore, most cases found that accidently by the examination of chest x-ray and a few of these cases are required for operative reconstruction because of respiratory distress and swallowing difficulties. Eventration of the diaphragm appears to be a congenital anomaly and a condition in which one leaf of the diaphragm is in abnormally high position and is markedly thinned and atrophic. The muscular component is either absent or greatly reduced-often limited to a small rim of muscle around the periphery.
This allows the stomach to angulate upward compressing the lung and shifting the heart and mediastinum to the opposite side.
Some authors believe that the resultant compression and displacement of intrathoracic organs are responsible for many deaths in tie newborn period. It is indeed surprising that severe symptoms always present acute volvulus. Acute volvulus of stomach has been associated with hiatal hernia as well as diaphrahmatic eventration and acute condition requires immediate operation. The type of gastric volvulus is two in majority cases. A) Organo-axial (Fig. 6-A). in whicli the stomach rotates around its long axis: B) Mescntero-axial (rig. 6-B), in which Lite rotation occurs from right to left, or less frequently from left to right.
Organo-axis volvulus occurs more commonly than does mesenterio-axial volvuls and any volvulus occurs in tie presence of intra-abdominal disease such as congenital or an acquired defect in the diaphragm.
The diagnosis of eventration of diaphragm associated with g stric volvulus can usually be made if it is considered.
The barium x-ray ahpearence of gastric vovulus and eventration is usually diagnostic with the combined triad of Borchardt criteria.
In the majority of cases of eventration, treatment is unnecessary but in those patients who have symptoms surgery should be undertaken. If the volvulus is secondary in type definitive treatment includes the repair of the abnormality within the abdominal cavity.
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