Volvulus Research Articles

Entrapment of a jejunocecostomy anastomosis in the epiploic foramen in a horse

A mare aged 9 years underwent surgical correction of a small intestinal volvulus using a side-to-side, hand-sewn jejunocecal anastomosis. Nine months after the jejunocecostomy, the horse developed colic signs and ultrasonographic examination revealed gas in the large colon in the upper right flank region and several enlarged loops of the small intestine in the lower right flank area. The differential diagnosis was right dorsal displacement of the large colon or small intestinal strangulation. The exploratory celiotomy found epiploic foramen entrapment (EFE) of the jejunocecostomy anastomosis, including parts of the distal jejunum and cecum. Manual reduction of herniation of the bowel in the epiploic foramen (EF) was impossible and the horse was euthanized. The postmortem gross finding revealed the enlarged edematous at the distal end of the jejunum and the initial body portion of the cecum had passed into the EF in the right-to-left (antegrade) direction. To the authors’knowledge, this is the first report of the antegrade epiploic foramen entrapment of a jejunocecostomy bowel part and this may be one of the complications encountered during the long-term survival period of a surgical jejunocecostomy in horses.

Gastric dilatation volvulus in dogs: utility of lactate as a predictor of survival

PICO question
 In dogs presenting with gastric dilatation volvulus, is an admission or pre-operative lactate level a reliable predictor of survival to discharge?
 
 Clinical bottom line
 Category of research question
 Prognosis
 The number and type of study designs reviewed
 15 studies (12 retrospective and 3 prospective) were critically appraised
 Strength of evidence
 Moderate
 Outcomes reported
 At a population level, lower blood lactate concentration, or lactate concentration that decreases following fluid resuscitation, are associated with a better prognosis.
 At a population level, higher blood lactate concentration, or lactate concentration that fails to decrease following fluid resuscitation, is associated with a worse prognosis. However, the lower sensitivity across studies means that a high lactate, or one that does not decrease following fluid therapy, should be interpreted more cautiously than a low lactate; i.e., low lactate predicts survival better than high lactate predicts non-survival.
 In all studies, there was a significant overlap in individual blood lactate concentration between survivors and non-survivors
 Conclusion
 Blood lactate level should only be used to help guide broad, cautiously worded conversations with owners as described above. It should not be used to give a prognosis for individual patients. The overlap between survivors and non-survivors, and the high overall survival rate, means that exploratory laparotomy should be advised irrespective of the blood lactate level
 
 How to apply this evidence in practice
 The application of evidence into practice should take into account multiple factors, not limited to: individual clinical expertise, patient’s circumstances and owners’ values, country, location or clinic where you work, the individual case in front of you, the availability of therapies and resources.
 Knowledge Summaries are a resource to help reinforce or inform decision making. They do not override the responsibility or judgement of the practitioner to do what is best for the animal in their care.

LBODP086 An Unusual Infant Case Of Gastric Volvulus Presenting With Dumping Syndrome

Abstract An 18-day female infant, born preterm small for gestational age (SGA), developed fasting hypoglycemia. A critical sample revealed an insulin level of 4.7 μIU/mL at the time of hyloglycemia (39 mg/dL) without ketoacidosis. Diazoxide therapy was started under the impression of transient neonatal hyperinsulinemia related to SGA, however, hypogycemia was developed on the 21st day of life. Targeted next generation sequencing (NGS) was performed for possible congenital hyperinuslinism. During octreotide therapy, postprandial hyperglycemia was incidentally detected at 27 days. Continuous glucose monitoring (CGM; Dexcom G6, San Diego, California) revealed postprandial hyperglycemia and subsequent hypoglycemia suggestive of dumping syndrome, although she had no prior history of surgery. An upper gastrointestinal series revealed the anomalous rotation of the stomach along the mesenteroaxial axis perpendicular to its longitudinal axis, implying gastric volvulus. The possibility of dumping syndrome caused by gastric volvulus was confirmed by stable glucose level in the euglucemic range using CGM after continuous nasojejunal feeding. She received laparoscopic gastropexy to anchor the stomach. Euglycemia was maintained after surgery and octreotide therapy was successfully discontinued. NGS identified no pathogenic variant for congenital hyperinsulinism. At 8 months of age, she exhibited catch-up growth and normal development. This is the first infant case of gastric volvulus presenting with dumping syndrome during diazoxide therapy for transient neonatal hyperinsulinism. Presentation: No date and time listed

Cecal Volvulus with Intestinal Malrotation: A Case Report

Cecal volvulus is a rare surgical emergency, it occurs when the caecum get entangled upon a mesenteric axis which can cause a decrease of the blood supply or complete or partial obstruction of the bowel lumen, the Intestinal malrotation is a rare etiology of the cecal volvulus occurring due to incomplete or faulty rotation and fixation of the gut during fetal life. In our case report the occurrence of these two anomalies together is found which a rare situation is. This is a report of a 35 year old man who presented with acute abdominal pain and intestinal obstruction. CT demonstrated a cecal volvulus complicated by colic perforation.

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Gastrointestinal Emergencies in Neonates: A Review Article.

Numerous emergencies that are life-threatening might presentin the newborn period of life. Thus, physicians need an in-depth understanding of such circumstances in order to treat critically ill neonates.Identification of these illnesses and choosing the appropriate course of action, which includes patient stabilization, differential diagnosis based on laboratory and imaging results, and well-guided therapy, are the responsibility of the emergency department staff. The most typical diagnoses in this kind of situation are severe bacterial infections, congenital heart illness, gastrointestinal crises (including malrotation with midgut volvulus, necrotizing enterocolitis, etc.), respiratory problems, neurologic abnormalities, and child abuse. Reviewing the most prevalent ailments of a severely unwell newborn in the emergency room is the major goal of this review article. In developing countries, neonatal mortality rates are a crucial determinant of their development. Management of emergencies especially in neonates can be very difficult and fatal if misdiagnosed. In this article, we will be discussing neonatal gastrointestinal (GI) emergencies.

Incarcerated Small Bowel inside A Slide Hernia Composed of Colon Wall Triggered by Left Bochdalek Hernia in Adult:An Extremely Rare Etiology of Acute Intestinal Volvulus

Acute abdomen triggered by acute bowel obstruction is common in clinical practice, which may be caused by various reasons such as inflammation, tumors, intussusception and incarcerated hernia,etc. Here by, we describe a young man who was a heavy phsical worker presented with an abdominal pain and a sudden onset for nearly a day duration, accompanied with frequent nausea and vomiting, which could be partially relieved on his standing position. Empty feeling with mild tenderness was palpable on his right lower quadrant abdomen and abnormal bowel sounds were heard in his left chest cavity. Acute abdominal intestinal incarcerated obstruction was demonstrated on computed tomography (CT) of the abdomen. Urgent laparascopic exploration unveiled a Bochdalek hernia with a 3 cm defect in diameter that was subsequently closed by continual suture after the incarcerated reduced. The key to success is early identification of characterized features on images such as chest X-ray and abdominal CT, combined with the abdominal pain attack relieved by standing or semi-recombent position. In addition, the defect of Bodalek hernia is recommended to take a continual suture with a slowly absorbed barbed suture so as to strenthen the firmeness of the diaphragm.

Gastric volvulus: A complication of hiatal hernia

Gastric volvulus: A complication of hiatal hernia

Should Radiological Assessment be Part of Core General Surgery Competency? A Survey of the General Surgery Residents

Introduction: Radiological assessment is an important skill to develop in general surgery training. Therefore, we aimed to determine general surgery residents’ points of view on receiving formal radiology didactics. Methods: We performed an anonymous survey of general surgery residents throughout the US. The survey queried the residents` postgraduate year, training program type, diagnostic radiology education in their training program, as well as the residents’ comfort level in interpreting various imaging modalities, followed by a series of images to assess the residents’ ability to interpret images showing various surgical disease processes. Results: A total of 365 residents responded to the survey. 76.6% of the respondent states that there is no structured didactic session in their program on radiological studies. However, 66.3% felt that interpretation of radiological images should be used to determine surgical competency and promotion to the next academic year. In terms of accurately reading images - 68.7% of the residents were able to read an x-ray showing cecal volvulus correctly, 51.9% were able to read a cholangiogram correctly, and 95.3% were correctly read an x-ray showing free under the diaphragm. Conclusion: Most residents favored having radiological assessments as part of the competency evaluation. Furthermore, a curriculum and inbuilt training structure that aims to ensure residents develop competent clinical image interpretation abilities may enhance the development and retention of such skills, ultimately influencing patient outcomes.

Torsion of congenital ovarian cyst in association with mid-gut volvulus: A rare presentation

Midgut volvulus is a life-threatening condition that can lead to bowel ischemia and devastating results with high mortality incidence.

S3626 Large Type IV Hiatal Hernia Complicated by Organo-Axial and Mesentero-Axial Gastric Volvulus: A Case Report

Introduction: A type IV hiatal hernia is characterized by displacement of the stomach along with other organs into the intrathoracic cavity and is associated with laxity of the peri-gastric ligaments. This condition is extremely rare, accounting for less than 5 percent of all hiatal hernias. Due to mechanical issues, paraoesophageal hernias can lead to serious complications such as gastric volvulus. Depending on the axis of rotation, gastric volvulus can be divided into organo-axial, mesentero-axial or a mixed type of volvulus. This case vignette discusses a rare case of a large type IV hiatal hernia with both organo-axial and mesentero-axial gastric volvulus. Case Description/Methods: A 75-year-old female with past medical history of a large hiatal hernia was referred to GI clinic for intermittent post-prandial and right sided non-exertional chest pain of a few years. She denied any associated shortness of breath, diaphoresis, palpitations, and nausea/vomiting. A subsequent diagnostic esophagogastroduodenoscopy (EGD) revealed a significant anatomic distortion of the stomach with a posteroinferior positioning of the pylorus and a large 10 cm paraoesophageal hernia with associated mucosal erythema, edema, and hematin material. To further characterize the anatomy, an upper GI series demonstrated a large type IV hiatal hernia with an intrathoracic stomach measuring 9.3 cm x 15.8 cm and evidence of both organo-axial and mesentero-axial gastric volvulus. Patient was referred to surgery for gastric detorsion, fixation, and repair of the large paraesophageal hernia. (Figure) Discussion: Gastric volvulus is a rare condition and can develop as a complication of a paraesophageal hernia. Due to fixation of the stomach along the GE junction and pylorus axis, the herniated stomach tends to rotate along this longitudinal axis resulting in an organo-axial volvulus. Less frequently, the stomach can rotate along the transverse axis resulting in a mesentero-axial volvulus. Organo-axial and mesentero-axial volvuli occurring together is extremely rare. Chronic gastric volvulus can present with nonspecific symptoms such as intermittent epigastric discomfort, postprandial fullness, nausea, dysphagia, dyspnea, or chest discomfort. Imaging via upper GI series or cross-sectional imaging are required to make the diagnosis. Chronic gastric volvulus secondary to the hiatal hernia can be managed surgically on a nonemergent basis with detorsion, fixation of the gastric volvulus and repair of the hiatal hernia.Figure 1.: Upper GI Series Demonstrated A Large Type IV Hiatal Hernia with An Intrathoracic Stomach measuring 9.3 cm x 15.8 cm.

S2217 A Rare Case of Synchronous Double Volvulus of the Sigmoid Colon and Cecum

Introduction: Colonic volvulus is one of the leading causes of large bowel obstruction. Synchronous cecal and sigmoid volvulus is a rare presentation. Cecal volvulus and sigmoid volvulus have traditionally been thought of as separate clinical presentations with distinct clinical features, radiological findings, and treatment modalities. We focus on the classical radiological findings, uncharacteristic presentations, and definitive treatment to prevent recurrence, morbidity, and mortality. Case Description/Methods: A 67-year-old female with a past medical history of severe chronic constipation secondary to stercoral colitis presents to the emergency department complaining of abdominal pain for 5 days. Pain is diffuse, and associated with nausea and vomiting. The last colonoscopy performed 4 years ago, was normal. The patient was in immense pain and was not able to provide further information. On presentation, the patient was afebrile, BP 127/52, HR 73, RR 16 breaths/min. The abdomen was distended, and peritoneal sounds were auscultated in all quadrants but were worse in lower quadrants bilaterally. X-ray of the abdomen showed pneumoperitoneum and dilated bowel related to stercoral colitis. Subsequent CT abdomen showed small volume ascites, hollow perforated viscus, markedly distended cecum with peri-cecal inflammatory changes, and significant wall thickening with inflammation in the sigmoid colon secondary to concurrent cecal and sigmoid volvulus. The patient immediately underwent exploratory laparotomy, ileocecectomy with primary anastomosis, sigmoidectomy with primary anastomosis, and abdominal washout (Figure). Discussion: When evaluating acute abdomen, we propose consideration of synchronous large bowel volvulus is a rare and easily missed etiology of large bowel obstruction due to challenging radiological presentation. Even with detailed cross-sectional imaging like CT scan, it is possible to miss coexisting cecal volvulus due to massively enlarged sigmoid volvulus causing mass effect. The preferred treatment is total or subtotal colectomy with or without anastomosis on a case-to-case basis. This approach provides the advantage of avoiding the risk of recurrence and histopathological analysis to rule out underlying malignancy. Commonly, only one type of large bowel volvulus is found radiologically, it is advisable to pay attention to the possibility of coexisting cecal volvulus and a definitive diagnosis being made intraoperatively.Figure 1.: A. Chest X-ray showing gas under diaphragm; B. Volvulous with dilated caecum and Sigmoid colon on Abdominal X-ray; C. Scout film of the CT scan abdomen; D. Twisted Caecum with dilated sigmoid colon on axial film.

S2173 A Twist of Fate: The Cecal Bascule

Introduction: Cecal volvulus is a rare clinical entity with an incidence of 2.8-7.1 per million per year and accounts for 1-2% of large bowel obstruction. The rarest type of cecal volvulus is cecal bascule, accounting for 5-20% of all cases. It occurs when the cecum folds up over itself in an anteromedial orientation with a competent ileo-cecal valve. This allows for gaseous and fluid distention. The pathogenesis is still unclear but the literature suggests that congenital or acquired adhesion may be responsible as a mobile cecum. Symptoms consist of abdominal pain, distention, nausea and obstipation. Diagnosis may be challenging due to its rarity. Here we present a male with an incidental imaging finding suggestive of cecal bascule. Case Description/Methods: An 82-year-old male patient with history of prostate cancer, atrial fibrillation on Apixaban, diabetes and chronic kidney disease who was consulted to gastroenterology services due to rectal bleeding. He reported an episode of intermittent rectal bleeding in the past year mostly secondary to straining due to constipation. Last colonoscopy on 2010 showed diverticulosis plus internal and external hemorrhoids; no polyps or masses. He denied abdominal pain, weight loss, or early satiety. Hemoglobin was stable and normal rectal exam. In view of risk vs benefits patient opted for CT colonography. Study with evidence of diverticulosis and a large cecal bascule. Upon follow-up, he reported feeling well and denied abdominal pain or recurrence of rectal bleeding. He had a complicated appendectomy 7 years ago. Patient was consulted to general surgery for possible cecopexy. Discussion: Cecal bascule is a rare subtype of cecal volvulus that mostly occur in older patients and usually presents with marked GI symptoms, such as obstruction, needing emergent treatment. Risk factors are mostly due to embryogenic defects or iatrogenic (abdominal surgery). Diagnosis is made via imaging study, such as CT, or laparoscopy showing the cecum folding upward resulting in obstruction. Management is mostly surgical with resection and cecopexy. Here with present a case of cecal bascule with a rare presentation of minimal symptoms. The patient had history of a complicated appendectomy most likely being the inciting factor of the cecal bascule. Most cases in literature present after a more recent surgical procedure. The importance of this case is to bring attention of this rare clinical entity, its diagnosis and how it may present with non-specific chronic symptoms.

S3380 Atherosclerotic Small Bowel Ischemia Causing Intestinal Obstruction and Volvulus

Introduction: Obstructions are the most common events requiring surgical intervention in the small intestine. Several factors can cause an obstruction, with adhesions from previous surgeries being most common. It is rare for the obstruction to be caused by volvulus of the small bowel, and increasingly more rare for that volvulus to be caused by ischemia due to atherosclerosis. Presented herein is a unique case of small bowel obstruction due to volvulus of the small bowel that resulted from severe bowel ischemia. Case Description/Methods: The case discusses the medical and surgical management of a 70-year-old man who presented to the emergency department with abdominal pain. After a thorough history, physical exam, and diagnostic testing, the patient was diagnosed with small bowel obstruction due to volvulus, secondary to atherosclerotic ischemia of the small intestine, and rushed to surgery. After the surgical intervention and hospital stay, the patient made a complete recovery and was asymptomatic at follow-up appointments. Discussion: Small bowel obstructions occur mostly due to adhesions from prior surgeries. It is exceedingly rare that they may occur due to volvulus. This case is unique in that the inciting event was significant small bowel ischemia, likely from uncontrolled hyperlipidemia and atherosclerosis as evidenced by the CT findings of a severely atherosclerotic abdominal aorta. The ischemia then made way for the necrotic segment of the small bowel to twist upon its mesentery and cause a closed loop obstruction and further compromise of the blood supply to the small intestine. The presentation of a volvulus in the small intestine is not as easily recognizable on radiographs as a sigmoid and cecal volvulus. The classic “birds beak” phenomenon characteristic of any volvulus on contrast enhanced plain film was not seen in this case. Imaging was consistent with a small bowel obstruction, but the etiology was unclear until an exploratory laparotomy was performed. It is likely that this patient had a chronic underlying process of mesenteric ischemia before presenting with this volvulus that was never diagnosed. Ischemia must be considered as a differential or possibly as an underlying factor for future management when working up a patient for bowel obstruction. Swift intervention in this scenario likely prevented outcomes such as perforation and severe hemodynamic instability. This patient would benefit from cholesterol lowering medications and possibly endovascular repair to prevent future recurrence.

S2027 Extrinsic Compression of the Hepatic Flexure from Metastatic Cholangiocarcinoma Masquerading as Cecal Bascule

Introduction: Cecal bascules are the rarest variant of cecal volvulus that involve upward folding of the cecum, without axial twisting or sigmoid involvement. We present a case in which a patient with a hepatic flexure obstruction from extrinsic compression masqueraded as a cecal bascule on imaging. Case Description/Methods: A 66-year-old woman with history of stroke, hypertension, recent obstructive cholestasis due to choledocholithiasis requiring biliary stent placement, presented with 3 days of right sided abdominal pain, 15lb weight loss and 3 weeks of constipation with thin stools. Computed Tomography (CT) revealed dilated loops of distal small bowel and cecum that folded anteriorly and superiorly with extensive pneumatosis (Figure A), consistent with cecal bascule (type III cecal volvulus). The ascending colon was dilated up to a decompressed hepatic flexure, where nonspecific bowel wall thickening was visualized. She had a normal colonoscopy a few months prior. The patient was initially managed conservatively, however a lower gastrointestinal series showed persistent obstruction at the hepatic flexure with bird-beak appearance (Figure B). She underwent an exploratory laparotomy that discovered a mass in the right upper quadrant involving the gallbladder and liver, causing extrinsic compression of the hepatic flexure and numerous omental nodules. Biopsies confirmed metastatic cholangiocarcinoma. The patient began evaluation for cancer staging, but ultimately passed one month after diagnosis. Discussion: The development of a cecal bascule is usually attributed to an abnormally mobile cecum due to improper development and insufficient fixation of the mesentery to the posterior parietal peritoneum. A mobile cecum may also be acquired in pregnancy due to enlargement of the uterus, or after abdominal surgery such as open appendectomies which require extensive division of peritoneal attachments to the cecum. Clinical presentation can be variable with abdominal pain, distention and nausea being most common symptoms and ranging to an acute abdomen and perforation. Diagnosis of type III cecal volvulus requires CT imaging confirming a distended cecum lying anterior to ascending colon. Treatment generally involves surgical resection of the affected bowel as colonoscopic detorsion may lead to recurrence. This is a unique case of an extrinsic malignant obstruction causing a cecal bascule, highlighting the importance of a comprehensive evaluation for underlying etiologies.Figure 1.: A: Cecal bascule with extensive pneumatosis on CT. B: Lower gastrointestinal series showing obstruction at hepatic flexure with bird-beak appearance.

Gastric volvulus in the mediastinum through a hiatal hernia

Hiatal hernia (HH) is gastric herniation through the oesophageal hiatus into posterior mediastinum. We present an uncommon case of congenital sliding HH in healthy child, with organo-axial gastric-volvulus and normal mid-gut rotation. A 3-month-old female, presented with worsening coffee-ground vomiting for the last 6 weeks. Medical history was unremarkable. She was severely dehydrated with a soft abdomen and no obvious abdominal masses. Initial blood tests revealed elevated White Cell Count (WCC) mainly neutrophils, C-Reactive Protein (CRP) and lactate levels with normal electrolytes. CXR reported discontinuity of left hemi-diaphragm with the stomach shadow occupying the left lower hemi-thorax. The upper GI contrast study and chest CT-scan revealed stomach, pylorus and liver lobe wholly located in the chest, occupying the posterior mediastinum. Both sides of the hemi-thorax were clear, with no evidence of mid-gut malrotation. Radiological images confirmed presence of a large defect in posterior diaphragm around the midline, with stomach and liver herniating into the chest. Following resuscitation, nasogastric tube insertion and consent, a laparotomy revealed organo-axial volvulus of stomach and incarceration, along with the presence of a complete sliding HH through a large defect. Complete reduction of herniated contents, fundoplication and primary closure of defect undertaken. Uneventful post-operative recovery and discharged from hospital after 10 days. We present an infant with complete sliding HH complicated with organo-axial gastric volvulus. Such cases although rare, require high suspicion and prompt management in view of gastric volvulus, as mortality is considerable. With prompt evaluation and adequate resuscitation, we were able to provide immediate optimal surgical treatment and avoid unnecessary complications.

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

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.

Diaphragmatic eventration with impending gangrenous organoaxial volvulus of the stomach: Role of timely intervention

Eventration of diaphragm is a rare entity and often is characterized by a developmental abnormality of the diaphragm musculature. The acute presentation of organoaxial volvulus with impending gangrene of stomach is a life-threatening event and requires emergency diagnosis and surgical intervention. A 45-year-old man visited our hospital for evaluation of upper abdominal discomfort. He had a feeling of fullness and discomfort in the upper abdomen for 3 years. These attacks lasted about 2 hours and were not usually severe but eventually presented with severe abdominal pain. The patient was explored as general condition was deteriorating. On exploration, it was found that there was huge organoaxial stomach volvulus with impending stomach gangrene. Emergency exploration, gastropexy, and plication of diaphragm was done. Early diagnosis and prompt intervention may avoid consequent gastric volvulus and complications,improving the overall outcome and mortality.

S2327 Gurvits Syndrome in Setting of Uncontrolled Diabetes and Acute Gastrointestinal Bleeding Successfully Treated with Extended Duration PPI Despite Continuing DOAC

Introduction: A young male with past medical history (PMH) of severely uncontrolled non-insulin dependent diabetes mellitus (NIDDM) with recurrent admissions for diabetic ketoacidosis (DKA) and hypertriglyceridemia-induced pancreatitis, both secondary to medication non-adherence, presented via emergency medical services (EMS) after being found unresponsive at home and subsequently developed acute esophageal necrosis (AEN) during a prolonged stay in the intensive care unit (ICU) for acute respiratory failure. He was successfully treated with extended duration of proton pump inhibitor (PPI) therapy and control of underlying risk factors despite being continued on anticoagulation. Case Description/Methods: A 39-year-old male with PMH of uncontrolled NIDDM presented was admitted for acute respiratory failure secondary to DKA and pneumonia. He was intubated and admitted to ICU, while continued on DKA protocol including antibiotics. GI was consulted for hematemesis and melena 2 weeks into hospitalization. EGD revealed circumferential black esophageal mucosa in the distal esophagus abruptly ending at the gastroesophageal junction (GEJ) and hiatal hernia. Recommendations included Intravenous (IV) proton pump inhibitor (PPI) and strict avoidance of naso/orgastric (NG/OG) tube. Follow up EGD few months after discharge showed remarkable improvement of mucosa as noted in Figures A and B, despite continuation of DOAC as per patient wishes for DVT developed during the stay. Discussion: AEN is a rare syndrome disproportionately reported in men which is characterized by circumferential black esophageal mucosa in the distal 2 thirds of the esophagus, abruptly ceasing at the GEJ. Ischemia is postulated to be an inciting event. Conditions associated with AEN are antibiotics, sepsis, gastric volvulus, hernia, DKA, malignancy, and prolonged vomiting. Symptoms of upper gastrointestinal bleeding (UGIB) and shock are common presentations. Although biopsy establishes diagnosis and rules out other causes, EGD finding is generally sufficient. Initial management consists of IV fluids and treatment of the underlying cause. IV PPI and nil per os (NPO) is recommended. NG/OG tubes are avoided unless vomiting or obstruction is present. Mortality is largely due to underlying disease rather than directly from AEN, hence supportive care results in resolution in most cases, as seen in our patient. Our case demonstrates the importance of addressing underlying causes, as well as PPI therapy, which can overcome continued anticoagulation.Figure 1.: A. Acute esophageal necrosis discovered on endoscopy while undergoing EGD for acute GI bleeding during ICU admission for DKA and acute respiratory failure requiring mechanical ventilation B. Resolution of acute esophageal necrosis with grossly normal mucosa on follow up endoscopy conducted after extended duration PPI therapy and relatively controlled diabetes.

S1997 Cecal Bascule: A Rare Cause of Large Bowel Obstruction

Introduction: Cecal bascule is a rare form of cecal volvulus, which is characterized by an anterior and superiorly displaced cecum in turn causing large bowel obstruction. It accounts for 0.01% of adult large bowel obstructions. Here we present a case of cecal bascule in a cirrhotic patient. Case Description/Methods: A 63-year-old female with history of alcoholic cirrhosis (MELD 20) and cesarean section presented to the emergency department with intermittent hematochezia and melena. At admission, she was hemodynamically stable with a hemoglobin of 5.7 g/dL. She underwent esophagogastroduodenoscopy (EGD) which demonstrated small esophageal varices without stigmata of a recent bleed, antral gastritis, and duodenitis. Due to a largely unrevealing EGD, she was scheduled to have a colonoscopy. However, the patient had difficulties tolerating the bowel prep due to increasing abdominal pain. An abdominal X-ray demonstrated a large gaseous lucency in the right mid abdomen below the level of the transverse colon which was concerning for cecal bascule. A computed tomography (CT) scan of the abdomen demonstrated a redundant cecum folding anteriorly with superior rotation into the upper right hemiabdomen without definite point of transition and diffuse small bowel dilation up to 4.3 cm. Findings were consistent with a cecal bascule. Patient underwent an exploratory laparotomy with right hemicolectomy. Patient had a prolonged, complicated post-operative course with multiorgan failure and finally died 30 days after the surgery (Figure). Discussion: Cecal bascule involves the upward folding of the cecum as opposed to an axial twisting of the colon as seen in more common types of cecal volvulus. For this phenomenon to occur, a patient will often have a mobile and redundant cecum that causes the volvulus. This may occur as a congenital anomaly secondary to a failed fusion in development between the ascending colon mesentery and the posterior parietal peritoneum. Additionally, this may be acquired from abdominal adhesions, pregnancy or even after a colonoscopy. Like other types of volvuli, treatment of cecal bascule requires surgical detorsion to prevent further complications. It is therefore important that cecal bascule be identified early for proper surgical planning and appropriate intervention. In our case, the poor outcome was due to the underlying decompensated cirrhosis.Figure 1.: Abdominal X-ray demonstrating a large gaseous lucency in the right mid abdomen near the transverse colon CT of the abdomen demonstrating an anteriorly and superiorly rotated cecum into the upper right hemiabdomen.