7197 Gastric volvulus causing respiratory failure successfully treated with percutaneous endoscopic gastrostomy tube placement.

Abstract

A 77-year-old female was brought to the casualty department as an emergency following respiratory arrest in a nursing home. She had vomited five hours prior to admission and subsequently became progressively breathless culminating in respiratory arrest. On arrival she had a Glasgow Coma Scale score of 3/15, was apyrexial, pulse 108/min, blood pressure 120/67 mmHg and was making minimal respiratory effort. She was obese, and had a history of heart failure for which she was on diuretics. Arterial blood gases analysis showed a severe respiratory acidosis, pH 6.9, pO283 mmHg, pCO2115 mmHg, bicarbonate 23.2 mmol/L. Emergency intubation and ventilation was undertaken. CXR showed a dilated stomach, which occupied approximately 50% of the left hemithorax. A nasogastric tube was passed, following which ventilation rapidly improved and extubation was possible. A similar episode had occurred six months beforehand, with similar radiological findings and was also successfully treated with nasogastric decompression. A barium meal was performed, which confirmed the presence of a partial gastric volvulus. Gastroscopy revealed a dilated lower oesophagus, partial torsion of the stomach and a small duodenal ulcer in the duodenal bulb. Ten days after admission the patient suffered a further respiratory arrest. She was unconscious and hypoventilating. A nasogastric tube was immediately passed, following which she recovered, without the requirement of intubation and ventilation. The NG tube was left in situ. She was felt to represent too great an anaesthetic risk for surgical gastropexy under general anaesthesia. A percutaneous endoscopic gastrostomy (PEG) tube was placed under local anaesthetic. The procedure was well tolerated and she was discharged back to her nursing home three days later, with instruction to deflate the stomach twice per day via the PEG. There have been no recurrences in the following six months. Gastric volvulus causing respiratory arrest is an extremely rare presentation in adult medicine, but has been described in paediatric practice. PEG tubes have been effective in decompressing the stomach in gastric volvulus in patients unfit for surgery. This provided the ideal solution for this patient and should be considered in patients with volvulus otherwise unfit for surgery.