Good History and High Suspicion of Gastric Volvulus in Patient With Known Hiatal Hernia Are Key to Better Outcomes

Abstract

Introduction: Gastric volvulus is relatively uncommon, potentially life-threatening entity that occurs when the stomach twists upon itself. We present a case with history of hiatal hernia that presented with Mesenteroaxial gastric volvulus. Mesenteroaxial gastric volvulus accounts for about one-third of the cases where stomach folds along its short axis from the lesser to greater curvature. Presentation of Case: A 79-year-old female with history of hiatal hernia, COPD, coronary artery disease and infrarenal abdominal aortic aneurysm (AAA) presented with epigastric pain, nausea and non-bilious/non-bloody vomiting. Reports having regular bowel movements. On exam: Temperature 98.3F, Blood Pressure 94/61, Heart Rate 82, Respiratory rate 22 and Oxygen saturation 93% on room air. Abdominal exam was significant for mild distention but otherwise soft and non-tender. Laboratory findings were notable for WBC 7.6 and Lactate 1.3. On bedside ultrasound was found to have severely dilated stomach and CT angiography of abdomen/pelvis was done to rule out dissection of AAA and further investigate ultrasound findings. It showed large hiatal hernia with gastroesophageal junction, pylorus and antrum above diaphragm and distended body of the stomach below suggestive of gastric volvulus (see image 1). She was managed with decompression with nasogastric tube and patient was kept NPO on IV fluids and IV protonix (PPI). Upper endoscopy (EGD) was performed and showed abnormal anatomical configuration of fundus and body of stomach (see image 2) were body was noted to loop up towards the diaphragm adjacent to the gastroesophageal junction and with great difficulty of intubating the pylorus. No evidence of torsion was seen. EGD finding were consistent with paraesophageal hernia type IV and mesenteroaxial gastric volvulus without signs of strangulation. Patient underwent laparoscopic paraesopphageal hernia and gastric volvulus repair and was doing well on postop clinic follow up. Conclusion: Gastric volvulus can range from a transient event, with mild symptoms of abdominal pain and vomiting to complete obstruction with ischemia and necrosis of the stomach. A good history and physical examination can provide the clues needed to make the presumptive diagnosis, which can then be confirmed with radiographic studies and EGD, ultimately leading to early surgical treatment which is essential to reduce the morbidity and mortality of gastric volvulus.Figure 1Figure 2Figure 3