PMC5039297_01
Anteroposterior (a) and lateral (b) projections of the abdominal X-ray. The distended stomach (black arrows) occupies epigastrium and mesogastrium; air-fluid level is present in the gastric fundus.
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fig1
At admission, a chest and abdominal X-ray was performed finding a severe gastric distension with an air-fluid level and normal diaphragmatic profile (Figure 1).
(a) Ultrasonography. The spleen is displaced caudal to the lower pole of the left kidney (yellow arrow). (b) Color Doppler ultrasound examination reveals a turbulent flow in splenic artery secondary to revascularization.
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fig2
The abdominal ultrasound showed a very mobile spleen displaced lower and medially; at the Doppler evaluation, the spleen vascular flow was present with increased turbulence (Figure 2).
CT scan with oral and intravenous contrast. CT scanogram (a), axial CT scan (b), and sagittal reconstruction (c) show the contrast-filled distended stomach, due to an organoaxial gastric volvulus. The coronal reconstruction (d) reveals a displaced spleen with hypoperfusion of the upper pole (yellow arrow).
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fig3
These features were corroborated by the oral and intravenous contrast CT scan (Figure 3), which showed a subdiaphragmatic organoaxial gastric volvulus.
Intraoperative findings: the stomach is rotated with the displacement of the cardia under the pyloric level (a); moreover, the spleen is rotated medially and displaced in the left flank (b).
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fig4
At surgery, we found a organoaxial gastric volvulus with the displacement of the cardia under the pyloric level (Figure 4(a)); moreover, we noticed a wandering spleen located in the left flank with the absence of short gastric vessels and both gastrosplenic and gastrophrenic ligaments (Figure 4(b)); the hiatal foramen and the diaphragm were normally conformed.
The splenopexy is performed by creation of a retroperitoneal pocket (a) and fixation of the spleen with nonabsorbable sutures mounted on small Teflon pledgets (b).
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Teflon pledgets (Figure 5).