Acute Gastric Volvulus Causing Splenic Avulsion and Hemoperitoneum

Abstract

INTRODUCTION Gastric volvulus (GV) is a rare entity, associated with significant mortality. Prompt diagnosis and treatment are imperative. It is characterized by abnormal rotation of the stomach along either its short or long axis, mesentero-axial (Figure 1) and organo-axial (Figure 2) volvulus respectively. Acute GV typically presents with pain and vomiting. When these symptoms are accompanied by an inability to pass a nasogastric tube (NGT) they are characteristic of GV and known as Borchardt's triad. The main consequence of the GV is foregut obstruction. Other complications can include ulceration, perforation, hemorrhage, pancreatic necrosis, omental avulsion and rarely, disruption of the splenic vessels or splenic rupture.Figure: The stomach rotates around its short axis through a perpendicular line connecting the greater and lesser curvatures of the stomach. The antrum becomes displaced above the gastroesophageal junction.Figure: Rotation of the stomach along its long axis through a line that connects the gastroesophageal junction and the pylorus.The antrum rotates anterosuperiorly and the fundus rotates posteroinferiorly. The greater curvature of the stomach comes to rest superior to the lesser curvature of the stomach in an inverted position.CASE REPORT A 66-year-old Hispanic female with history of stroke with residual hemiparesis, presented with acute, 7/10, diffuse abdominal pain associated with multiple episodes of non-bloody emesis of food contents. Her exam revealed a scar from a previous gastrostomy tube (PEG), abdominal distention and moderate tenderness to palpation diffusely. Her laboratory evaluation revealed normocytic anemia. A CT scan reported a grossly distended stomach with gastric outlet obstruction, and a moderate amount of hyperdense intraperitoneal fluid, highly concerning for hemoperitoneum (Figure 3). An NGT was placed for decompression of the stomach and 1.5L of non-bloody gastric fluid was aspirated with concomitant resolution of her presenting symptomatology. Gastroscopy revealed a deeply J-shaped stomach and an easily accessible, unremarkable duodenum. A repeat CT scan revealed a linear defect in the spleen and showed the stomach laying in a different anatomic position.Figure: CT of abdomen and pelvis with contrast showing a markedly distended abdomen without focal wall thickening. The J-shaped stomach is rotated along its long axis, displaying a gastric volvulus. Fluid, consistent with blood, is seen tracking along the paracolic gutters and the pelvis.DISCUSSION GV, particularly when accompanied by other complications is rare. This case is unusual in its presentation, with 2 complications of GV, and its setting, in a patient with a history of previous PEG. Our patient experienced GV causing splenic avulsion by traction of the splenogastric ligaments, and resultant hemoperitoneum. The treatment of GV involves reduction of the stomach to its anatomic position and PEG tube gastropexy to prevent repeat torsion. However, the deeply J shaped anatomy of our patients stomach allowed ample unfixed proximal stomach to result in organoaxial rotation despite history of a PEG. As a result of this case, we urge a keen clinical eye and high level of suspicion be maintained in all cases presenting with Borchardt's triad.