Chest Pain with a Twist: A Gastric Volvulus Case Presentation

Abstract

Purpose: Chest pain is experienced by 25% of people in the United States and accounts for 1-2% visits to physicians. Of this 25%, 30% is of noncardiac origin. Gastric volvulus is a potentially life-threatening condition that can easily be misdiagnosed unless the symptoms are recognized. A 75 year old male presented for evaluation for chest pain and possible non-ST elevation myocardial infarction (NSTEMI). He had a normal electrocardiogram with mildly elevated troponin. Physical exam revealed an uncomfortable male with stable vital signs but with continuous hiccups, nausea and retching. CT of the chest and abdomen was initially read as large hiatal hernia. Endoscopy was done which showed ischemic gastric mucosa with clear transition point. Later the CT was re-read by another staff radiologist to report large fluid-filled stomach with configuration suggestive of organoaxial gastric volvulus. Patient underwent laparoscopic reduction and repair but had a very difficult hospital course with septic shock, fungemia, renal and respiratory failure. Although gastric volvulus is a rare condition, early diagnosis and surgical intervention are crucial because mortality from an acute gastric volvulus is reported to be as high as 30-50%. Diagnosis was delayed in this case because of a misread on the first CT chest and also because of the mildly elevated troponin. This case represents a rare condition that presented as a common complaint. If the patient's symptoms were recognized, he may have been diagnosed and treated earlier.Figure: CT showing large fluid-filled structure in the mediastinum.Figure: Chest radiograph showing gastric shadow with abnormal contour in mediastinal area.