Chronic Gastric Volvulus: A Rare Yet Important Consideration in Chronic Abdominal Pain

Abstract

Purpose: Gastric volvulus has been described in the medical literature for centuries. The acute presentation of gastric volvulus is dramatic and rarely missed, and it is this type that is usually quoted in the literature. The sub acute or chronic type, however, is infrequently recognized early in its presentation because it is accompanied by nonspecific symptomatology. We represent a rare case of intrathoracic chronic organoaxial gastric volvulus. Methods: A 56-year-old male with past medical history of status post laparoscopic hernia repair twelve years ago was evaluated for postprandial sharp epigastric pain, lasting for a few minutes, rarely for several hours, bloating and early satiety for preceding three years. Empiric trial of proton pump inhibitors did not alleviate his symptoms. Patient underwent EGD. We were able to pass the scope past the gastroesophageal junction but were unable to locate the pylorus. The mucosa of the gastric body appeared twisted in a clock-wise direction. Chronic gastric volvulus was suspected, so next patient had a barium upper gastrointestinal series that showed a large paraesophageal hernia with organoaxial volvulus. Most of the stomach was intrathoracic except small portion of the antrum and duodenal bulb. Patient was referred for surgery. Conclusion: Gastric volvulus can be classified by anatomic type (organoaxial, mesenteroaxial, or combined), extent (total or partial, severity (acute or chronic) and etiology (primary or secondary). The most common type is organoaxial which usually presents as an acute volvulus due to compromised vascular supply. The presentation is often sub acute for mesenteroaxial volvulus. Our case is unique due to its sub acute presentation in setting of an organoaxial volvulus. Chronic gastric volvulus presents with nonspecific chronic abdominal pain which makes it difficult to distinguish from the common etiologies causing it, hence delaying its diagnosis and treatment. Diagnosis is made typically during endoscopy and confirmed by upper gastrointestinal barium study. Acute gastric volvulus is a surgical emergency whereas chronic gastric volvulus may be repaired endoscopically as well.Figure: An organoaxial gastric volvulus.