Indications and Limitations of Conservative Treatment for Chronic Gastric Volvulus in Children

Indications and Limitations of Conservative Treatment for Chronic Gastric Volvulus in Children | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Indications and Limitations of Conservative Treatment for Chronic Gastric Volvulus in Children Kazuki Shirane, Kyoko Mochizuki, Ryo Takahashi, Satoshi Tanaka, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8027209/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Chronic gastric volvulus in children is generally well managed with conservative treatment; however, this may not always be successful. This study aimed to evaluate the effectiveness and limitations of conservative treatment for pediatric chronic gastric volvulus. Methods We retrospectively reviewed the medical records of patients diagnosed with chronic gastric volvulus in our hospital between January 2013 and September 2023. Gastric volvulus was diagnosed based on upper gastrointestinal studies or characteristic radiographic findings. The collected data included patient characteristics, types of gastric volvulus, methods and success rates of conservative treatment, and details of any surgical interventions performed. Results A total of 51 patients were included in this study. Of these, 80% were aged ≤ 12 months. The overall success rate of conservative treatment was 94%. The most common conservative approaches included defecation support (75%) and encouragement of burping (61%). Success rates varied by age group, with 100% success observed in patients aged ≤ 5 years. Three patients, aged 9, 12, and 14 years, underwent laparoscopic gastropexy. Conclusion Chronic gastric volvulus in young children responded well to conservative treatment. In contrast, school-aged children were more likely to require surgical intervention. chronic gastric volvulus conservative treatment children infant Figures Figure 1 Introduction Gastric volvulus refers to a condition in which the stomach rotates at least 180° around an axis [ 1 ]. Organoaxial gastric volvulus occurs when the stomach rotates along an axis parallel to its longitudinal axis, whereas mesenteroaxial gastric volvulus occurs when the stomach rotates along an axis perpendicular to the longitudinal axis [ 1 ]. A combined type includes features of both organoaxial and mesenteroaxial volvulus [ 1 ]. In addition, gastric volvulus is classified as acute or chronic according to its clinical onset [ 1 – 3 ]. Acute gastric volvulus typically has a sudden onset and requires immediate intervention [ 1 , 4 , 5 ]. In contrast, chronic gastric volvulus often presents with nonspecific symptoms such as non-bilious vomiting, epigastric distention, and failure to thrive [ 1 ]. Chronic gastric volvulus is generally considered to respond well to conservative treatment [ 5 – 7 ]. However, indications for surgical intervention in pediatric chronic gastric volvulus remain controversial. This study aimed to evaluate the effectiveness of conservative treatment for chronic gastric volvulus in the pediatric population and investigate the indications for surgical intervention. Materials and methods Patients diagnosed with chronic gastric volvulus at Kanagawa Children’s Medical Center between January 2013 and September 2023 were included in the study. This study was approved by the Institutional Review Board of the Kanagawa Children’s Medical Center (IRB No. 156-6). Gastric volvulus was primarily diagnosed based on the findings from the upper gastrointestinal (UGI) contrast study. In patients who did not undergo a UGI study, the diagnosis was based on characteristic findings on plain abdominal radiographs as defined in previous reports [ 8 , 9 ]. These included marked gastrointestinal distention between the stomach and colon, cranial displacement of the transverse colon, the gastric double-bubble sign, a horizontally oriented dilated stomach, and the presence of air–fluid levels in the upper abdomen. Gastric volvulus was classified as acute or chronic based on the onset of symptoms. Patients were categorized as chronic if their symptoms persisted for a prolonged period without requiring urgent treatment. We retrospectively reviewed the medical records of all included patients. The following data were collected: age at diagnosis, sex, presenting symptoms, comorbidities, type of gastric volvulus, methods of conservative treatment, success rate of conservative treatment, and length of follow-up. The success of conservative management was defined as cases that could be managed without surgical intervention. Results A total of 51 patients were identified during the study period. The patient characteristics are summarized in Table 1 . The median age of the patients at diagnosis was 2 months. Male patients comprised 39% of the total population. The most frequent symptom was nonbilious vomiting (71%), followed by abdominal distention (45%), impaired eructation (33%), constipation (27%), and failure to thrive (12%). Of the 51 patients, 12 (24%) had at least one comorbidity. Nine patients had a history of being born with low birth weight (LBW), including five classified as LBW and four as extremely low birth weight (ELBW). Other comorbidities were observed in five patients, including Angelman syndrome (n = 1), asplenia (n = 1), autism spectrum disorder (n = 1), chromosomal abnormalities involving chromosome 19 (n = 1), SCN2A gene mutation (n = 1), severe mental retardation (n = 1), and single ventricle (n = 1). Table 1 Patient characteristics N = 51 Age at diagnosis, months 2 [ 1 , 5 ] Male, n 20 (39) Symptoms, n Non-bilious vomiting 36 (71) Abdominal distention 23 (45) Impaired eructation 17 (33) Constipation 14 (27) Failure to thrive 6 (12) Abdominal pain 2 (4) Feeding intolerance 2 (4) Laryngeal secretion retention 1 (2) Comorbidities, n Low birth weight infant 9 (18) Angelman syndrome 1 (2) Asplenia 1 (2) Autism spectrum disorder 1 (2) Chromosomal abnormality involving chromosome 19 1 (2) SCN2A gene mutation 1 (2) Severe mental retardation 1 (2) Single ventricle 1 (2) UGI study performed, n 27 (53) Type of gastric volvulus*, n Organoaxial 18 (35) Mesenteroaxial 7 (14) Combined 2 (4) Not available 24 (47) Selected treatment, n Defection support† 38 (75) Encouraging burping 31 (61) Prokinetic agents 15 (29) PPI or H2 blocker 4 (8) Success rate of conservative treatment, n 48 (94) Follow-up period, months 4 [ 1 , 10 ] Values are presented as median [IQR] or number of cases (%). Abbreviations: UGI, upper gastrointestinal; PPI, proton pump inhibitor. * Gastric volvulus was classified according to the type in patients who underwent UGI. † Defection support includes enema, rectal stimulation with cotton swabs, and rectal bougie. A UGI contrast study was performed on 27 patients. Among them, 18 had organoaxial volvulus, seven had mesenteroaxial volvulus, and two had combined volvulus. The remaining 24 patients were diagnosed based on a combination of clinical and plain abdominal radiographic findings. The characteristic plain abdominal radiographic findings observed in this study are shown in Fig. 1 . The volvulus type could not be determined in cases without a UGI study. Conservative treatment includes various approaches. Defecation support was the most popular treatment, including enema, rectal stimulation with cotton swabs, and rectal bougies. It was performed in 75% of all cases. Encouragement of burping was the second most commonly employed intervention, applied in 61% of all patients. Prokinetic (29%) and antacid agents (8%)—the latter including proton pump inhibitors (PPI) or H2 blockers—were also used. The success rate of conservative treatment was 94%. The median follow-up period after diagnosis was 4 months. Table 2 shows the age group distribution and corresponding success rates of conservative treatment. Most patients (80%) were under 12 months of age, with those aged 6 months or younger accounting for 76%. There was a decreasing trend in the number of cases with increasing age: five patients were between 1 and 5 years old, four patients were between 6 and 12 years old, and the remaining patients were between 13 and 18 years old. A total of 30 patients (59%) had available body weight (BW) Z-score data from baseline to final follow-up. In the ≤ 12 months group, the median BW Z-score increased by 0.3. Although the number of cases was limited in the other groups, no improvement in the BW Z-score was observed in patients aged > 1 year. The success rate of conservative treatment was higher in the younger age groups. Patients aged ≤ 12 months and those aged 1–5 years were successfully managed with conservative treatment alone. In contrast, surgical intervention was required in 50% (2/4) of patients aged 6–12 years and in 100% (1/1) of those aged 13–18 years. Table 2 Patient distribution, weight change, and conservative treatment outcomes according to age group. Age group at diagnosis Number of cases Change in BW Z score from baseline to final follow-up (SD) Follow-up period (months) Success of conservative treatment n/N* baseline final Δ Z score ≤ 12 months 41 (80) 26/41 -0.4 -0.25 0.3 5 41 (100) 1–5 years 5 (10) 2/5 -3.3 -3.35 -0.05 3 5 (100) 6–12 years 4 (8) 1/4 1.4 1.3 -0.1 1.5 2 (50) 13–18 years 1 (2) 1/1 -2.2 -2.2 0 3 0 (0) Values are presented as number of cases (%), n/N, and median. Abbreviation: BW, body weight. * n/N = patients with both baseline and final follow-up data available/total number in the group. Three patients underwent surgical intervention during the study period. Patient 1 was a 9-year-old girl with marked dilatation of the small bowel and colon on abdominal radiograph. Given the potential risk of acute exacerbation due to gastric volvulus, laparoscopic gastropexy was planned. Although conservative treatment with daily enemas was attempted before surgery, no improvement in bowel dilatation was observed. Patient 2 was a 12-year-old boy who presented with abdominal distension and pain. As his symptoms progressively worsened and he was unable to attend school, laparoscopic gastropexy was performed to achieve early resolution. Patient 3 was a 14-year-old girl with autism spectrum disorder and severe intellectual disability. She exhibited significant aerophagia and associated intestinal dilatation; however, enemas could not be administered because the patient refused. Therefore, laparoscopic gastropexy was indicated. Discussion This study demonstrated that conservative treatment can yield favorable outcomes in patients with chronic gastric volvulus. Therapeutic strategies aimed at relieving both upper and lower gastrointestinal distention, such as defecation support and encouraging burping, have proven to be especially beneficial. Notably, the success rate of conservative management varied across age groups; younger patients with immature gastric fixation ligaments responded well to conservative treatment, whereas school-aged children commonly required surgical intervention. Chronic infantile gastric volvulus is relatively common and highly responsive to conservative treatment. Although some recurrent or intermittent cases are included, Cribbs et al. reported that 71% of gastric volvulus cases without acute onset occurred in infants aged ≤ 12 months [ 1 ]. The reported success rate of conservative treatment in infantile chronic gastric volvulus varies but is generally high, ranging from 74% to 90.9% [ 5 , 10 ]. The present study also demonstrated a predominance of infants (41/51 patients, 80%) and a high success rate in this population (41/41, 100%), which is consistent with previous findings. This high incidence in infancy and favorable response to conservative treatment are likely associated with the immaturity of the gastric fixation ligaments. Normal fixation of the stomach is achieved by the gastrophrenic, gastrohepatic, gastrosplenic, and gastrocolic ligaments [ 1 ]. These ligaments are physiologically weak during infancy, allowing the stomach to rotate more easily [ 8 ]. Consequently, infants are prone to gastric volvulus with chronically persistent symptoms. As these ligaments strengthen with age [ 8 ], infantile chronic gastric volvulus is usually managed conservatively rather than surgically. Conservative management is generally centered on postural therapy and may also include pharmacological agents such as prokinetic drugs and antacids [ 2 , 6 , 7 , 10 ]. Notably, this study demonstrated a high utilization rate of measures aimed at relieving gastrointestinal distention. Infants commonly swallow air during feeding, and often exhibit bowel dilatation [ 11 ]. Bowel dilatation is one of the contributing factors for chronic gastric volvulus, as it pushes the loosely fixed stomach cranially and promotes gastric rotation [ 4 , 6 , 10 ]. Previous reports have emphasized patient positioning to reduce air passage through the pylorus [ 6 ] or promote rapid gastric emptying [ 10 ], whereas we employed gastrointestinal decompression through gas evacuation, including burping and defecation support. These measures reduce bowel dilatation and, consequently, the forces driving gastric rotation. Based on these findings, we propose that conservative treatment focusing on ligamentous immaturity is an effective strategy for the treatment of infantile gastric volvulus. Patients beyond infancy, particularly school-aged children, remain a challenging population for the conservative treatment of chronic gastric volvulus. Sawaguchi et al. reported that 77% of patients aged 2 years or older required surgical intervention [ 8 ]. Our study also demonstrated an increased tendency toward surgical intervention in the older age groups. Several factors may contribute to this, with the most important being the absence or laxity of the gastric fixation ligaments. Consistent with this finding, intraoperative findings revealed ligamentous weakness in all patients who underwent laparoscopic gastropexy. As these ligaments are not reinforced during growth, additional surgical fixation is often required. Another challenge in school-aged children is that conservative treatments, such as enemas, depend on patient cooperation. Infants can passively undergo these procedures, whereas school-aged children cannot. This study demonstrates that difficulties are especially marked in school-aged children with intellectual disabilities. Therefore, these patients were considered appropriate candidates for early gastropexy. Clinically, the differences in social functioning between infants and school-aged children are critical factors in determining treatment strategies. Although the effectiveness of conservative treatment often requires considerable time, school-aged children experiencing severe difficulty in school life require rapid symptom relief. Therefore, early surgical intervention should be considered for them. This study has a few limitations. First, although the sample size was larger than that in previous reports, it remained limited, particularly in patients beyond infancy. Second, the follow-up period was relatively short as many patients discontinued follow-up after symptom improvement. A longer follow-up may have revealed a more pronounced effect on weight gain. Third, UGI contrast studies were not performed in all cases. Since the type of gastric volvulus could not be determined in approximately half of the patients, we were unable to thoroughly evaluate the impact of volvulus type on prognosis. Although all the patients who underwent gastropexy had mesenteroaxial volvulus, it remains unclear whether the mesenteroaxial type is associated with a higher risk of adverse outcomes. Conclusion Conservative treatment is indicated for infantile chronic gastric volvulus and is associated with a high success rate. In contrast, patients beyond infancy tend to require surgical intervention. In infants with immature gastric fixation ligaments, bowel dilatation due to swallowing air during feeding can elevate the stomach and result in gastric volvulus. Therefore, procedures aimed at relieving gastrointestinal distention may be an effective therapeutic approach. In older children, the absence or laxity of the gastric fixation ligaments is mainly associated with the development of volvuli. This anatomical difference often leads to the need for surgical intervention, such as gastropexy, in this age group. Declarations Conflicts of interest The authors declare no conflicts of interest. Ethics approval This study was approved by the Institutional Review Board of the Kanagawa Children’s Medical Center (IRB No. 156-6). Consent to participate Informed consent was obtained using an opt-out approach, with details of the study posted on the hospital website. Patients and their family members were given the opportunity to decline participation. Consent to publish Consent to publish was waived by the institutional review board because all data were anonymized, and no identifiable personal information was included. Funding The authors did not receive any specific grant from any organization. Author Contribution K.S. and K.M. contributed to the conceptualization, methodology, and investigation. K.S. wrote the original manuscript. K.M. revised the original manuscript. R. T., S. T., R. M., T. K., H. U., and N. K. critically reviewed the manuscript. All authors approved the final version of the manuscript. Acknowledgement Acknowledgements: We would like to thank Editage (www.editage.jp) for English language editing. Data Availability The datasets for this study can be obtained from the corresponding author upon a reasonable request. References Cribbs RK, Gow KW, Wulkan ML (2008) Gastric volvulus in infants and children. Pediatrics 122:e752–e762. https://doi.org/10.1542/peds.2007-3111 Porcaro F, Mattioli G, Romano C (2013) Pediatric gastric volvulus: diagnostic and clinical approach. Case Rep Gastroenterol 7:63–68. https://doi.org/10.1159/000348758 McCarthy LC, Raju V, Kandikattu BS, Mitchell CS (2014) Infantile feeding difficulties: it is not always reflux. Glob Pediatr Health 1:2333794X14553624. https://doi.org/10.1177/2333794X14553624 Al-Salem AH (2007) Acute and chronic gastric volvulus in infants and children: who should be treated surgically? Pediatr Surg Int 23:1095–1099. https://doi.org/10.1007/s00383-007-2010-y Inanc I, Yildiz S, Basaran UN, Avlan D (2025) The conservative approach for infantile gastric volvulus. Pediatr Surg Int 41:131. https://doi.org/10.1007/s00383-025-06007-9 Honna T, Kamii Y, Tsuchida Y (1990) Idiopathic gastric volvulus in infancy and childhood. J Pediatr Surg 25:707–710. https://doi.org/10.1016/s0022-3468(05)80001-6 Elhalaby EA, Mashaly EM (2001) Infants with radiologic diagnosis of gastric volvulus: are they over-treated? Pediatr Surg Int 17:596–600. https://doi.org/10.1007/s003830100001 Sawaguchi S, Ohkawa H, Kemmotsu H, Akiyama H, Nakajo T, Kitamura T (1981) Idiopathic gastric volvulus in infancy and childhood. Z Kinderchir 32:218–223. https://doi.org/10.1055/s-2008-1063263 Duman L, Savas MC, Büyükyavuz BI, Akcam M, Sandal G, Aktas AR (2013) Early diagnostic clues in neonatal chronic gastric volvulus. Jpn J Radiol 31:401–404. https://doi.org/10.1007/s11604-013-0213-9 Bautista-Casasnovas A, Varela-Cives R, Fernandez-Bustillo JM et al (2002) Chronic gastric volvulus: is it so rare? Eur J Pediatr Surg 12:111–115. https://doi.org/10.1055/s-2002-30161 Sferra TJ, Heitlinger LA (1996) Gastrointestinal gas formation and infantile colic. Pediatr Clin North Am 43:489–510. https://doi.org/10.1016/s0031-3955(05)70417-x Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Organoaxial gastric volvulus occurs when the stomach rotates along an axis parallel to its longitudinal axis, whereas mesenteroaxial gastric volvulus occurs when the stomach rotates along an axis perpendicular to the longitudinal axis [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. A combined type includes features of both organoaxial and mesenteroaxial volvulus [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn addition, gastric volvulus is classified as acute or chronic according to its clinical onset [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Acute gastric volvulus typically has a sudden onset and requires immediate intervention [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In contrast, chronic gastric volvulus often presents with nonspecific symptoms such as non-bilious vomiting, epigastric distention, and failure to thrive [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Chronic gastric volvulus is generally considered to respond well to conservative treatment [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, indications for surgical intervention in pediatric chronic gastric volvulus remain controversial. This study aimed to evaluate the effectiveness of conservative treatment for chronic gastric volvulus in the pediatric population and investigate the indications for surgical intervention.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003ePatients diagnosed with chronic gastric volvulus at Kanagawa Children\u0026rsquo;s Medical Center between January 2013 and September 2023 were included in the study. This study was approved by the Institutional Review Board of the Kanagawa Children\u0026rsquo;s Medical Center (IRB No. 156-6). Gastric volvulus was primarily diagnosed based on the findings from the upper gastrointestinal (UGI) contrast study. In patients who did not undergo a UGI study, the diagnosis was based on characteristic findings on plain abdominal radiographs as defined in previous reports [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. These included marked gastrointestinal distention between the stomach and colon, cranial displacement of the transverse colon, the gastric double-bubble sign, a horizontally oriented dilated stomach, and the presence of air\u0026ndash;fluid levels in the upper abdomen. Gastric volvulus was classified as acute or chronic based on the onset of symptoms. Patients were categorized as chronic if their symptoms persisted for a prolonged period without requiring urgent treatment.\u003c/p\u003e\u003cp\u003e We retrospectively reviewed the medical records of all included patients. The following data were collected: age at diagnosis, sex, presenting symptoms, comorbidities, type of gastric volvulus, methods of conservative treatment, success rate of conservative treatment, and length of follow-up. The success of conservative management was defined as cases that could be managed without surgical intervention.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 51 patients were identified during the study period. The patient characteristics are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The median age of the patients at diagnosis was 2 months. Male patients comprised 39% of the total population. The most frequent symptom was nonbilious vomiting (71%), followed by abdominal distention (45%), impaired eructation (33%), constipation (27%), and failure to thrive (12%). Of the 51 patients, 12 (24%) had at least one comorbidity. Nine patients had a history of being born with low birth weight (LBW), including five classified as LBW and four as extremely low birth weight (ELBW). Other comorbidities were observed in five patients, including Angelman syndrome (n\u0026thinsp;=\u0026thinsp;1), asplenia (n\u0026thinsp;=\u0026thinsp;1), autism spectrum disorder (n\u0026thinsp;=\u0026thinsp;1), chromosomal abnormalities involving chromosome 19 (n\u0026thinsp;=\u0026thinsp;1), SCN2A gene mutation (n\u0026thinsp;=\u0026thinsp;1), severe mental retardation (n\u0026thinsp;=\u0026thinsp;1), and single ventricle (n\u0026thinsp;=\u0026thinsp;1).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePatient characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;51\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge at diagnosis, months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale, n\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20 (39)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSymptoms, n\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNon-bilious vomiting\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36 (71)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAbdominal distention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23 (45)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImpaired eructation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17 (33)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConstipation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14 (27)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFailure to thrive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (12)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAbdominal pain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFeeding intolerance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLaryngeal secretion retention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComorbidities, n\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLow birth weight infant\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (18)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAngelman syndrome\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAsplenia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAutism spectrum disorder\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChromosomal abnormality involving chromosome 19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eSCN2A\u003c/em\u003e gene mutation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSevere mental retardation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSingle ventricle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUGI study performed, n\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27 (53)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eType of gastric volvulus*, n\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOrganoaxial\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18 (35)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMesenteroaxial\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (14)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCombined\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNot available\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24 (47)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSelected treatment, n\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDefection support\u0026dagger;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e38 (75)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEncouraging burping\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31 (61)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProkinetic agents\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15 (29)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePPI or H2 blocker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSuccess rate of conservative treatment, n\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e48 (94)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFollow-up period, months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003eValues are presented as median [IQR] or number of cases (%).\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003eAbbreviations: UGI, upper gastrointestinal; PPI, proton pump inhibitor.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003e* Gastric volvulus was classified according to the type in patients who underwent UGI.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u0026dagger; Defection support includes enema, rectal stimulation with cotton swabs, and rectal bougie.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eA UGI contrast study was performed on 27 patients. Among them, 18 had organoaxial volvulus, seven had mesenteroaxial volvulus, and two had combined volvulus. The remaining 24 patients were diagnosed based on a combination of clinical and plain abdominal radiographic findings. The characteristic plain abdominal radiographic findings observed in this study are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The volvulus type could not be determined in cases without a UGI study.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eConservative treatment includes various approaches. Defecation support was the most popular treatment, including enema, rectal stimulation with cotton swabs, and rectal bougies. It was performed in 75% of all cases. Encouragement of burping was the second most commonly employed intervention, applied in 61% of all patients. Prokinetic (29%) and antacid agents (8%)\u0026mdash;the latter including proton pump inhibitors (PPI) or H2 blockers\u0026mdash;were also used. The success rate of conservative treatment was 94%. The median follow-up period after diagnosis was 4 months.\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the age group distribution and corresponding success rates of conservative treatment. Most patients (80%) were under 12 months of age, with those aged 6 months or younger accounting for 76%. There was a decreasing trend in the number of cases with increasing age: five patients were between 1 and 5 years old, four patients were between 6 and 12 years old, and the remaining patients were between 13 and 18 years old. A total of 30 patients (59%) had available body weight (BW) Z-score data from baseline to final follow-up. In the \u0026le;\u0026thinsp;12 months group, the median BW Z-score increased by 0.3. Although the number of cases was limited in the other groups, no improvement in the BW Z-score was observed in patients aged\u0026thinsp;\u0026gt;\u0026thinsp;1 year. The success rate of conservative treatment was higher in the younger age groups. Patients aged\u0026thinsp;\u0026le;\u0026thinsp;12 months and those aged 1\u0026ndash;5 years were successfully managed with conservative treatment alone. In contrast, surgical intervention was required in 50% (2/4) of patients aged 6\u0026ndash;12 years and in 100% (1/1) of those aged 13\u0026ndash;18 years.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePatient distribution, weight change, and conservative treatment outcomes according to age group.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAge group at diagnosis\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eNumber of cases\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e\u003cp\u003eChange in BW Z score from baseline to final follow-up (SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eFollow-up period (months)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSuccess of conservative treatment\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en/N*\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ebaseline\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003efinal\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eΔ Z score\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;12 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e41 (80)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26/41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-0.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e-0.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e41 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u0026ndash;5 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2/5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-3.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e-3.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e5 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u0026ndash;12 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1/4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e2 (50)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13\u0026ndash;18 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1/1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-2.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e-2.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003eValues are presented as number of cases (%), n/N, and median.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003eAbbreviation: BW, body weight.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003e* n/N\u0026thinsp;=\u0026thinsp;patients with both baseline and final follow-up data available/total number in the group.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThree patients underwent surgical intervention during the study period. Patient 1 was a 9-year-old girl with marked dilatation of the small bowel and colon on abdominal radiograph. Given the potential risk of acute exacerbation due to gastric volvulus, laparoscopic gastropexy was planned. Although conservative treatment with daily enemas was attempted before surgery, no improvement in bowel dilatation was observed. Patient 2 was a 12-year-old boy who presented with abdominal distension and pain. As his symptoms progressively worsened and he was unable to attend school, laparoscopic gastropexy was performed to achieve early resolution. Patient 3 was a 14-year-old girl with autism spectrum disorder and severe intellectual disability. She exhibited significant aerophagia and associated intestinal dilatation; however, enemas could not be administered because the patient refused. Therefore, laparoscopic gastropexy was indicated.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study demonstrated that conservative treatment can yield favorable outcomes in patients with chronic gastric volvulus. Therapeutic strategies aimed at relieving both upper and lower gastrointestinal distention, such as defecation support and encouraging burping, have proven to be especially beneficial. Notably, the success rate of conservative management varied across age groups; younger patients with immature gastric fixation ligaments responded well to conservative treatment, whereas school-aged children commonly required surgical intervention.\u003c/p\u003e\u003cp\u003eChronic infantile gastric volvulus is relatively common and highly responsive to conservative treatment. Although some recurrent or intermittent cases are included, Cribbs et al. reported that 71% of gastric volvulus cases without acute onset occurred in infants aged\u0026thinsp;\u0026le;\u0026thinsp;12 months [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The reported success rate of conservative treatment in infantile chronic gastric volvulus varies but is generally high, ranging from 74% to 90.9% [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The present study also demonstrated a predominance of infants (41/51 patients, 80%) and a high success rate in this population (41/41, 100%), which is consistent with previous findings. This high incidence in infancy and favorable response to conservative treatment are likely associated with the immaturity of the gastric fixation ligaments. Normal fixation of the stomach is achieved by the gastrophrenic, gastrohepatic, gastrosplenic, and gastrocolic ligaments [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. These ligaments are physiologically weak during infancy, allowing the stomach to rotate more easily [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Consequently, infants are prone to gastric volvulus with chronically persistent symptoms. As these ligaments strengthen with age [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], infantile chronic gastric volvulus is usually managed conservatively rather than surgically. Conservative management is generally centered on postural therapy and may also include pharmacological agents such as prokinetic drugs and antacids [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Notably, this study demonstrated a high utilization rate of measures aimed at relieving gastrointestinal distention. Infants commonly swallow air during feeding, and often exhibit bowel dilatation [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Bowel dilatation is one of the contributing factors for chronic gastric volvulus, as it pushes the loosely fixed stomach cranially and promotes gastric rotation [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Previous reports have emphasized patient positioning to reduce air passage through the pylorus [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] or promote rapid gastric emptying [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], whereas we employed gastrointestinal decompression through gas evacuation, including burping and defecation support. These measures reduce bowel dilatation and, consequently, the forces driving gastric rotation. Based on these findings, we propose that conservative treatment focusing on ligamentous immaturity is an effective strategy for the treatment of infantile gastric volvulus.\u003c/p\u003e\u003cp\u003ePatients beyond infancy, particularly school-aged children, remain a challenging population for the conservative treatment of chronic gastric volvulus. Sawaguchi et al. reported that 77% of patients aged 2 years or older required surgical intervention [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Our study also demonstrated an increased tendency toward surgical intervention in the older age groups. Several factors may contribute to this, with the most important being the absence or laxity of the gastric fixation ligaments. Consistent with this finding, intraoperative findings revealed ligamentous weakness in all patients who underwent laparoscopic gastropexy. As these ligaments are not reinforced during growth, additional surgical fixation is often required. Another challenge in school-aged children is that conservative treatments, such as enemas, depend on patient cooperation. Infants can passively undergo these procedures, whereas school-aged children cannot. This study demonstrates that difficulties are especially marked in school-aged children with intellectual disabilities. Therefore, these patients were considered appropriate candidates for early gastropexy. Clinically, the differences in social functioning between infants and school-aged children are critical factors in determining treatment strategies. Although the effectiveness of conservative treatment often requires considerable time, school-aged children experiencing severe difficulty in school life require rapid symptom relief. Therefore, early surgical intervention should be considered for them.\u003c/p\u003e\u003cp\u003eThis study has a few limitations. First, although the sample size was larger than that in previous reports, it remained limited, particularly in patients beyond infancy. Second, the follow-up period was relatively short as many patients discontinued follow-up after symptom improvement. A longer follow-up may have revealed a more pronounced effect on weight gain. Third, UGI contrast studies were not performed in all cases. Since the type of gastric volvulus could not be determined in approximately half of the patients, we were unable to thoroughly evaluate the impact of volvulus type on prognosis. Although all the patients who underwent gastropexy had mesenteroaxial volvulus, it remains unclear whether the mesenteroaxial type is associated with a higher risk of adverse outcomes.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eConservative treatment is indicated for infantile chronic gastric volvulus and is associated with a high success rate. In contrast, patients beyond infancy tend to require surgical intervention. In infants with immature gastric fixation ligaments, bowel dilatation due to swallowing air during feeding can elevate the stomach and result in gastric volvulus. Therefore, procedures aimed at relieving gastrointestinal distention may be an effective therapeutic approach. In older children, the absence or laxity of the gastric fixation ligaments is mainly associated with the development of volvuli. This anatomical difference often leads to the need for surgical intervention, such as gastropexy, in this age group.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflicts of interest\u003c/strong\u003e\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eEthics approval\u003c/h2\u003e\u003cp\u003eThis study was approved by the Institutional Review Board of the Kanagawa Children\u0026rsquo;s Medical Center (IRB No. 156-6).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003cp\u003eInformed consent was obtained using an opt-out approach, with details of the study posted on the hospital website. Patients and their family members were given the opportunity to decline participation.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003cp\u003e Consent to publish was waived by the institutional review board because all data were anonymized, and no identifiable personal information was included.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThe authors did not receive any specific grant from any organization.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eK.S. and K.M. contributed to the conceptualization, methodology, and investigation. K.S. wrote the original manuscript. K.M. revised the original manuscript. R. T., S. T., R. M., T. K., H. U., and N. K. critically reviewed the manuscript. All authors approved the final version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eAcknowledgements: We would like to thank Editage (www.editage.jp) for English language editing.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets for this study can be obtained from the corresponding author upon a reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCribbs RK, Gow KW, Wulkan ML (2008) Gastric volvulus in infants and children. Pediatrics 122:e752\u0026ndash;e762. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1542/peds.2007-3111\u003c/span\u003e\u003cspan address=\"10.1542/peds.2007-3111\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePorcaro F, Mattioli G, Romano C (2013) Pediatric gastric volvulus: diagnostic and clinical approach. Case Rep Gastroenterol 7:63\u0026ndash;68. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1159/000348758\u003c/span\u003e\u003cspan address=\"10.1159/000348758\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcCarthy LC, Raju V, Kandikattu BS, Mitchell CS (2014) Infantile feeding difficulties: it is not always reflux. Glob Pediatr Health 1:2333794X14553624. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/2333794X14553624\u003c/span\u003e\u003cspan address=\"10.1177/2333794X14553624\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAl-Salem AH (2007) Acute and chronic gastric volvulus in infants and children: who should be treated surgically? Pediatr Surg Int 23:1095\u0026ndash;1099. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00383-007-2010-y\u003c/span\u003e\u003cspan address=\"10.1007/s00383-007-2010-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eInanc I, Yildiz S, Basaran UN, Avlan D (2025) The conservative approach for infantile gastric volvulus. Pediatr Surg Int 41:131. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00383-025-06007-9\u003c/span\u003e\u003cspan address=\"10.1007/s00383-025-06007-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHonna T, Kamii Y, Tsuchida Y (1990) Idiopathic gastric volvulus in infancy and childhood. J Pediatr Surg 25:707\u0026ndash;710. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/s0022-3468(05)80001-6\u003c/span\u003e\u003cspan address=\"10.1016/s0022-3468(05)80001-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eElhalaby EA, Mashaly EM (2001) Infants with radiologic diagnosis of gastric volvulus: are they over-treated? Pediatr Surg Int 17:596\u0026ndash;600. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s003830100001\u003c/span\u003e\u003cspan address=\"10.1007/s003830100001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSawaguchi S, Ohkawa H, Kemmotsu H, Akiyama H, Nakajo T, Kitamura T (1981) Idiopathic gastric volvulus in infancy and childhood. Z Kinderchir 32:218\u0026ndash;223. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1055/s-2008-1063263\u003c/span\u003e\u003cspan address=\"10.1055/s-2008-1063263\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDuman L, Savas MC, B\u0026uuml;y\u0026uuml;kyavuz BI, Akcam M, Sandal G, Aktas AR (2013) Early diagnostic clues in neonatal chronic gastric volvulus. Jpn J Radiol 31:401\u0026ndash;404. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11604-013-0213-9\u003c/span\u003e\u003cspan address=\"10.1007/s11604-013-0213-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBautista-Casasnovas A, Varela-Cives R, Fernandez-Bustillo JM et al (2002) Chronic gastric volvulus: is it so rare? Eur J Pediatr Surg 12:111\u0026ndash;115. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1055/s-2002-30161\u003c/span\u003e\u003cspan address=\"10.1055/s-2002-30161\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSferra TJ, Heitlinger LA (1996) Gastrointestinal gas formation and infantile colic. Pediatr Clin North Am 43:489\u0026ndash;510. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/s0031-3955(05)70417-x\u003c/span\u003e\u003cspan address=\"10.1016/s0031-3955(05)70417-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"chronic gastric volvulus, conservative treatment, children, infant","lastPublishedDoi":"10.21203/rs.3.rs-8027209/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8027209/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eChronic gastric volvulus in children is generally well managed with conservative treatment; however, this may not always be successful. This study aimed to evaluate the effectiveness and limitations of conservative treatment for pediatric chronic gastric volvulus.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe retrospectively reviewed the medical records of patients diagnosed with chronic gastric volvulus in our hospital between January 2013 and September 2023. Gastric volvulus was diagnosed based on upper gastrointestinal studies or characteristic radiographic findings. The collected data included patient characteristics, types of gastric volvulus, methods and success rates of conservative treatment, and details of any surgical interventions performed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eA total of 51 patients were included in this study. Of these, 80% were aged\u0026thinsp;\u0026le;\u0026thinsp;12 months. The overall success rate of conservative treatment was 94%. The most common conservative approaches included defecation support (75%) and encouragement of burping (61%). Success rates varied by age group, with 100% success observed in patients aged\u0026thinsp;\u0026le;\u0026thinsp;5 years. Three patients, aged 9, 12, and 14 years, underwent laparoscopic gastropexy.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eChronic gastric volvulus in young children responded well to conservative treatment. In contrast, school-aged children were more likely to require surgical intervention.\u003c/p\u003e","manuscriptTitle":"Indications and Limitations of Conservative Treatment for Chronic Gastric Volvulus in Children","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-20 00:51:45","doi":"10.21203/rs.3.rs-8027209/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bb38ba56-e485-463b-a19e-2521f97faa24","owner":[],"postedDate":"November 20th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-21T17:54:02+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-20 00:51:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8027209","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8027209","identity":"rs-8027209","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}