Manual Endoscopic De-rotation of a Mesenteroaxial Gastric Volvulus due to Paraesophageal Hernia

Abstract

Figure: No Caption available.Purpose: Gastric volvulus is characterized by rotation of the stomach upon itself on either its short or long axis. It is a rare entity that occurs later in life with 80 to 90 percent of cases occurring after the fifth decade. The etiology may be either primary or secondary to an anatomic defect such as a paraesophageal or diaphragmatic hernia. The symptoms may occur in a wide spectrum from minimal or intermittent discomfort to more severe abdominal pain and vomiting to gastric outlet obstruction and ischemia. We present the case of an 82-year-old female with no significant medical history who presented as an outpatient with post-prandial coughing, nausea, and vomiting. Physical exam was unremarkable. Upper endoscopy was performed for further evaluation. The endoscope was advanced into the stomach and upon initial inspection, the orientation of the stomach was abnormal and appeared twisted. Retroflexion revealed that the patient had a paraesophageal hiatal hernia with a mesenteroaxial type gastric volvulus. This was evident by inappropriate positioning of the antrum and duodenum in the patient's chest cavity. In order to advance the endoscope to the duodenum, slightly increased scope pressure was used. Once the endoscope reached the duodenal bulb, it was then advanced more distally into the duodenum. At that point, the small dial was locked forward and the endoscope was carefully withdrawn using right torque to straighten out the stomach. Once in the stomach, retroflexion as performed confirming that the stomach now appeared to have normal orientation. Mesenteroaxial volvulus, as was present in our case, occurs when the rotation of the stomach is along the short axis through a line perpendicular to the greater and lesser curvatures. It is less commonly associated with an anatomic defect and it's usually a partial rotation, meaning less than 180 degrees. Organoaxial volvulus occurs when there is rotation along the long axis of the stomach through a line connecting the gastroesophageal junction and pylorus. This usually presents as a more acute process with a greater risk of strangulation and vascular compromise, which occurs in up to 30% of cases. The management of gastric volvulus consists of gastric decompression and a method to derotate the stomach and fix anatomic defects if possible. Management may either be surgical or endoscopic depending on the etiology of the volvulus and whether the patient is a good surgical candidate or not. Our patient subsequently underwent PEG tube placement for gastropexy after discussion in the office. Symptoms of dysphagia and chronic cough improved and completely resolved. PEG tube was eventually removed in the office three months after placement.