Atypical Presentation of Gastric Volvulus

Abstract

Gastric volvulus has been reported in all age groups, however, it is typically diagnosed in the elderly. Organo-axial volvulus is the most common type, followed by the mesentero-axial and the combined types. Depending on the etiology, gastric volvulus can also be classified as primary (idiopathic) or secondary. Primary gastric volvulus occurs due to abnormalities of the gastric ligaments that lead to failed gastric fixation. Secondary gastric volvulus may be due to local anatomic abnormalities, including paraesophageal and diaphragmatic hernias, phrenic nerve paralysis, and atypical anatomy of adjacent organs. We report a 68-year-old female with a past medical history significant for gastric ulcer, who presented with fever and was admitted for sepsis of unknown etiology. Physical examination was noncontributory. Laboratory results demonstrated normal white blood cell count, hemoglobin of 8.5 g/dL, hematocrit 27%, and platelet count of 178,000 cells/L. Fecal occult blood test was positive. As part of the sepsis work-up, a computed tomography (CT) scan of the abdomen revealed rotation of the stomach along the long axis, suggestive of organo-axial volvulus. Upper gastrointestinal (GI) series demonstrated herniation of the entire stomach through the diaphragmatic esophageal hiatus. The stomach was rotated upon itself, which corroborated the CT findings of organo-axial volvulus. No associated obstruction, ulceration, malrotation, or masses were identified. Subsequent esophagogastroduodenoscopy (EGD) revealed esophagitis in the distal third of the esophagus with spiral rotation of the gastric mucosal folds, which confirmed the diagnosis of organo-axial volvulus. Surgical intervention was not indicated. Volvulus rarely involves the stomach. The range of presentations can vary from incidental radiographic findings to life-threatening emergencies, depending on the rate of progression and extent of gastric rotation. Acutely, patients can present with chest pain, abdominal pain, and vomiting. Abdominal distention, rigidity, and guarding can be noted on physical examination. Confirmatory studies include X-ray and CT. Treatment of acute gastric volvulus involves laparoscopic and/or endoscopic procedures/maneuvers, depending on the severity of symptoms and surgical eligibility of the patient. Chronic gastric volvulus can be managed conservatively or by laparoscopic and/or endoscopic interventions.Figure 1Figure 2Figure 3