S3577 Chronic Intrathoracic Gastric Volvulus Management: Could Less Be More?

Abstract

Introduction: Chronic intrathoracic gastric volvulus usually presents with mild vague symptoms requiring high suspicion index to diagnose. Treatment can be either endoscopic or surgical. Nevertheless, neither approach is always ideal. Endoscopic management carries a high risk of gastric perforation, while surgical management may not be suitable due to the risk of anesthesia. In the following case report and literature review we evaluate the role of non-interventional conservative management in high-risk surgical patients with chronic intrathoracic gastric volvulus who experience breakthrough clinical symptoms. Case Description/Methods: An 88-year-old woman with history of dementia and hysterectomy presented for abdominal pain and vomiting. Vital signs and laboratory work up were stable. CT scan of the abdomen with contrast showed the stomach to be largely contained within the right hemithorax and rotated along its long axis compatible with an organoaxial volvulus, yet was nondilated nor obstructed, with contrast visualized throughout nondilated loops of small bowel which seem to be chronic in etiology as there were intrathoracic bowel loops on abdominal imaging six months prior (Figure A). Review of prior images noted the presence of the intrathoracic stomach on a CT scan done 12 years prior (Figure B). The patient was deemed high risk for sedation and anesthesia, for either endoscopic or surgical management, given the history of worsening dementia, debilitated medical condition, and diminished PO intake with malnutrition. She was started on TPN then 2 days later was switched to PO as her appetite and oral intake improved with frequent re-orientation and her family attempting to orally feed her. On evaluation one-month later, the patient had no more abdominal symptoms, continued to have maintain oral intake, with considerable improvement of her mental status and physical capabilities. Discussion: In this report, we demonstrated that conservative management is, perhaps, a more appropriate approach in patients with chronic gastric volvulus who are poor endoscopic or surgical candidates. Furthermore, our patient’s mental status and ability to tolerate oral diet has improved with adequate supportive measures (frequent re-orientation; meeting needs for nutrition, fluids, and sleep). Nevertheless, our patient remains at a high-risk form symptom recurrence given the history of abdominal hysterectomy for a leiomyoma, and thus close monitoring is necessary for symptom recurrence of the uncorrected gastric volvulus.Figure 1.: Computed tomography scan of the abdomen (axial view) performed on this admission (on the left (A)) vs 12 years prior (on the right (B)) Figure legend: The arrow points to the intrathoracic gastric volvulus.