Gastric Volvulus Presenting as Chronic, Intermittent Chest Pain and Retching of Unclear Etiology

Abstract

AIM: To describe a case of gastric volvulus which presented as chronic, intermittent chest pain and retching. CASE REPORT: A 59 yo female presented for further evaluation after relocating from another area. Her past medical history was unremarkable and she was taking only pantoprazole each day. She related a one year history of severe, intermittent lower chest pain with associated retching. Symptoms occurred exclusively in the intraprandial and early postprandial period. Symptoms occurred a few times each week and led to multiple ER visits. She underwent extensive cardiac evaluation, blood testing, gallbladder sonography, abdominal CT scanning and upper GI endoscopy (EGD). Her prior gastroenterologist detected a “moderate-sized” hiatal hernia and non-dysplastic, ultra-short-segment Barrett's esophagus (“irregular z-line”) at the time of EGD. Given her symptoms and her new diagnosis of Barrett's esophagus one year earlier, I recommended repeat EGD which revealed a large hiatal hernia (with approximately half of the stomach being intrathoracic) and there appeared to be a paraesophageal component. At this point, it was strongly suspected that her symptoms were related to the endoscopic findings. An upper GI series confirmed that a large portion of the stomach was intrathoracic, and there was organoaxial gastric volvulus (see Figure 1). The patient was urgently referred for surgical consultation and she underwent intervention. After nearly 2 years of follow-up, she has had durable resolution of all of her previous symptoms.Figure 1CONCLUSION: Chronic episodic chest pain in association with meal-related retching should raise the specter of intermittent gastric volvulus, especially in a patient with a history of a hiatal hernia. Although a bit less usual, in this case, the chronic symptoms were related to an organoaxial, as opposed to a mesenteroaxial gastric volvulus. Surgical repair was successful in alleviating the patient's symptoms.