Abstract
Introduction: Gastric volvulus is characterized by rotation of the stomach. The exact incidence is unknown. There are very few cases of volvulus of stomach have been reported. It is a rare condition that has peak incidence after age 50 and is considered a surgical emergency. A 69-year-old female with significant past medical history of GERD for 15 years presented to the emergency department (ED) with an episode of hemethemesis and melena. She stated that her GERD symptoms were controlled with proton pump inhibitor. The patient denied any abdominal pain, nausea, dizziness, shortness of breath, or chest pain. She has never had an EGD or colonoscopy done in the past. Physical exam showed BT 36.7, HR 80/min, BP 150/90 mmHg. Abdominal exam revealed melena from rectal exam. Lab showed Hb 13.2 gm/dl, WBC 10100 /mcL, platelet 287000 /mcL. CXR was done and showed a large hiatal hernia. The patient was started on pantoprazole drip, intravenous fluid, and made NPO for EGD. EGD was done and showed ulceration of esophagus with twisting of rugal fold and constriction of gastric body, which is compatible with esophagitis and gastric volvulus. Subsequently, the CT scan of chest and abdomen with IV contrast was done and showed large hiatal hernia containing the majority of the stomach with configuration, and organoaxial volvulus. Surgery was done and revealed total herniation of the entire stomach up into the large hernia at the level of diaphragm with twisted stomach, which was reduced back to the abdominal cavity. After the surgery, the patient had no complications and tolerated diet well. She was discharged from the hospital on the following day. Gastric volvulus is a rare and life-threatening condition that needs emergent surgery. There are two types: organoaxial and mesenteroaxial. Organoaxial volvulus, which was found in our patient, is the more common type, representing approximately 59% of cases. Our patient presented with hematemesis and melena, which is a rare presentation due to reflux esophagitis. The mechanism of hemethemesis is thought to be secondary to mucosal sloughing from mucosal tear and ischemia. The gold standard in the diagnosis of volvulus is barium swallow, which showed sensitivity in 14 out of 25 cases. CT scan is recommended to give more information about the position and anatomy. Non-operative therapy may be successful in selected patients, but surgical intervention is still a treatment of choice to avoid complications such as strangulation and ischemia. The surgical management of gastric volvulus requires de-rotation and reduction of the hernia. Laparoscopic approach is recommended in some literature because of its minimal invasiveness and because it carries a success rate.
Published Version
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