Hiccups: A Subtle Sign of Gastric Volvulus?

Abstract

Purpose: Volvulus is defined as an abnormal twisting of bowel upon itself resulting in luminal obstruction. This often occurs in the small intestine of pediatric patients with malrotation leading to obstruction. It is also seen in the large intestine, most commonly causing obstruction in the cecal and sigmoid regions. Another less common condition is gastric volvulus. Acute gastric volvulus is an emergency and an accurate timely diagnosis is essential. We present two cases of gastric volvulus where a major complaint of both patients was hiccups. These cases are reported to alert physicians to the possibility of hiccups as a subtle but important finding to suggest the diagnosis of gastric volvulus in the appropriate clinical setting. This is important because untreated gastric volvulus can potentially lead to incarceration and mesenteric ischemia with a high mortality. Results: Case 1: A 63 year old man presented with a one week history of nausea, vomiting, abdominal pain and progressively worsening hiccups. Physical exam showed some abdominal distention with mild diffuse tenderness. CT of the abdomen showed a distended, fluid-filled stomach with a twisting pattern consistent with an organoaxial gastric volvulus. Exploratory laparotomy showed a dilated stomach and paraesophageal hernia. Hernia repair was performed and the patient did well after surgery. Case 2: An 89 year old man presented with complaints of epigastric pain, nausea, vomiting, coffee ground emesis, and progressively worsening hiccups. Four months prior, an EGD had shown the presence of a large hiatal hernia. Presenting symptoms and known history of hiatal hernia suggested a possible diagnosis of gastric volvulus. Abdominal CT was consistent with a mesenteroaxial gastric volvulus confirming our clinical diagnosis. The patient was taken to the operating room, and a laparoscopic reduction of his gastric volvulus was performed. Conclusion: Gastric volvulus is an uncommon but potentially devastating condition if not diagnosed in a timely manner. In 1904 Borchadt described the classic triad of epigastric pain, retching and inability to pass a nasogastric tube in patients with a gastric volvulus. In our cases, an interesting finding was the presence of hiccups in both patients. Irritation of the diaphragm by a sliding gastric volvulus or paraesophageal hernia could theoretically trigger hiccups. In the presence of signs and symptoms suggestive of gastric volvulus, it may be appropriate for physicians to inquire about the presence of hiccups while obtaining the patient's history.