Organoaxial Volvulus Research Articles

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.

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.

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.

659. ORGANOAXIAL GASTRIC VOLVULUS DETERMINING GASTROESOPHAGEAL REFLUX DISEASE: A FORGOTTEN RELATION CAUSE

Abstract Gastric volvulus is a rare clinical and occurs when the stomach rotates 180° in its transverse or longitudinal axis. Symptoms may range from mild abdominal pain to volvulus necrosis. Gastroesophageal reflux disease (GERD) is not very often associated with abdominal gastric volvulus. Usually, the volvulus is primary and results from anatomical ligament defects. Organoaxial volvulus is the most common type and is defined by the rotation of the stomach around the Pylorus or Gastroesophageal Junction. Two cases will be presented where the treatment of organo-axial gastric volvulus was performed by video laparoscopy. The literature revision will try to bring some aspects of the problems in missing the diagnosis of the volvulus before operation. Two male patients, 24 and 47 years old, underwent surgery, both with extra-esophageal symptoms of GERD associated with symptoms of gastroparesis. Endoscopy, barium swallow and gastrography, manometry, pHmetry, and scintigraphy gastric emptying test were performed, showing a delayed gastric emptying time leading to reflux in both patients. Both patients had a good evolution after surgery. The release of the gastric anatomical ligaments was performed, as well as the rotated gastric fundus. The gastric fundus was used to perform a partial fundoplication, with the stomach being fixed to the pillars and diaphragmatic surface, fixing the stomach in a normal anatomical position. Gastric volvulus can be an unexpected cause of GERD, and the symptoms usually are refractory without surgical treatment. The appropriate surgical technique can bring good results and symptom relief to patients.

A tale of two twists: mesentero-axial and organo-axial sigmoid volvulus.

Sigmoid volvulus is a potentially devastating and life-threatening condition associated with sigmoid colon redundancy. Many of the classical radiological signs are considered to represent the two adjacent loops of bowel in a mesentero-axial volvulus. However, limited case reports and series have reported on an organo-axial subtype of sigmoid volvulus. This clinical entity is not widely understood. In this study, we assess the radiological and clinical features of mesentero-axial and organo-axial sigmoid volvulus. After institutional board approval (CH62/6/2016-228), all computed tomography (CT) studies from 2011 to 2017 reported as sigmoid volvulus at a single institution were reviewed. The cases were reviewed by three radiologists retrospectively and the course of the bowel followed with a focus on assessing its rotational axis. In each case, the sigmoid volvulus was independently subclassified as mesentero-axial or organo-axial volvulus based on the axis of rotation of the volvulus. In addition, X-ray signs including disproportionate sigmoid dilatation, distended inverted 'U' in sigmoid, coffee bean sign, opposed wall sign, direction of apex of sigmoid loop, liver overlap sign, northern exposure sign and proximal colonic dilatation and CT features including whirl sign, 'X' marks the spot sign, split wall sign and number of transition points were reported for each case. The clinical management and outcomes including morbidity, mortality, endoscopic decompression and need for surgery were also evaluated. The subtype of volvulus was correlated with the above X-ray signs, CT features and clinical management and outcomes. Statistical analysis was conducted using Stata/MP, version 15 (StataCorp LP, College Station, TX, USA). A total of 38 scans were reviewed. There were 19 patients identified. Of these, six (32%) were reported as mesentero-axial and 13 (68%) as organo-axial volvulus. No X-ray signs were able to distinguish the two types of volvulus. The number of transition points on CT was predictive of volvulus subtype (OR 25, 95% CI: 1.30-1295.30, P = 0.01). Within the limitations of a small cohort, there was no statistically significant difference in unsuccessful endoscopic decompression, need for colectomy, repeated admissions or mortality between the groups. This study has demonstrated that organo-axial sigmoid volvulus may be as common as mesentero-axial volvulus. Distinguishing organo-axial from mesentero-axial volvulus can be achieved on CT, but not on abdominal X-ray. The number of transition points (two for mesentero-axial and one for organo-axial) may be used as a diagnostic feature for differentiating the two forms of volvulus.

Acute primary gastric volvulus occurring after overeating in a 12-year-old girl

Gastric volvulus is a rare cause of recurrent abdominal pain or vomiting. This report presents a case of a 12-year-old girl with acute gastric volvulus and 2-hour history of epigastric pain after overeating. Computed tomography showed severe gastric distension without other abnormal findings. The gastric fluid decompressed through a nasogastric tube was approximately 4,000 mL in volume and non-bilious in color. Upper gastrointestinal series showed organo-axial volvulus without intestinal malrotation. Emergency laparotomy was performed. Because the color of stomach was pinkish, detorsion of the volvulus and gastropexy was performed. Postoperatively, the girl recovered uneventfully.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Colonic Volvulus and Acute Colonic Pseudo-Obstruction.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Colonic Volvulus and Acute Colonic Pseudo-Obstruction.

Chest Pain of Atypical Etiology: A Type IV Paraesophageal Hernia

A 59-year-old man with a history of coronary artery disease presented to the emergency department with chest “heaviness,” comparable with his prior myocardial infarction, and a “mass” sensation in his chest while denying any gastrointestinal symptoms. He was tachypneic to a rate of 28 breaths per minute but hemodynamically stable. His electrocardiogram was unchanged from prior studies and laboratory data were unremarkable. An anteroposterior chest radiograph (Figure A) demonstrated a large retrocardiac hiatal hernia with a visible air fluid level (white arrows). Follow-up computed tomography angiography of the chest, abdomen, and pelvis revealed the entirety of the stomach (yellow arrows) and most of the transverse colon (red arrows) within the mediastinum appreciable in sagittal (Figure B), coronal (Figure C), and transverse (Figure D) views. Given the inclusion of extragastric abdominal viscera within the hernia, it was classified as type IV paraesophageal hernia (types I-III are delineated by varying involvement of the esophagus and gastric fundus). Predisposing risk factors include a large defect in the phrenoesophageal membrane, and an increased laxity in the esophageal hiatus. Postdischarge, an upper gastrointestinal series was obtained illustrating organoaxial volvulus and the patient is now being evaluated for laparoscopic bowel reduction and diaphragmatic repair to preempt the risk of incarceration, strangulation, perforation, bleeding, or respiratory compromise.

Gastric Volvulus Associated with Eventration of Diaphragm

Diaphragmatic eventration is an abnormally elevated hemidiaphragm in thoracic cavity with poorly developed musculature. This condition can lead to abnormal displacement of intra-abdominal organs. It usually remains asymptomatic in early life. It presents later with respiratory and occasionally gastrointestinal complications. A clinical case of eventration of diaphragm, displacement of the splenic flexure of colon, omentum and spleen into thoracic cavity with gastric volvulus is uncommon. Gastric volvulus occurs when the stomach twists around one of its axis. It is commonly along its long axis (organoaxial volvulus) and less commonly along the vertical axis (mesenteroaxial).Mortality rate of gastric volvulus range from 30%-50%. Hence early diagnosis and prompt intervention prevents development of necrosis and perforation of stomach. We report a case of 30year old male having left sided diaphragmatic eventration associated with organoaxial gastric volvulus and displaced intra-abdominal organs treated with successful surgical intervention. Key words: Eventration; Diaphragm; Gastric; Volvulus; Malrotation; Organo-axial; Mesenteroaxial, Gastric outlet obstruction, Derotation; Gastropexy.

Gastric Volvulus: A Multidisciplinary Approach and Conservative Treatment

Gastric volvulus can be defined as an abnormal rotation of the stomach. It can be both an emergency and a chronic intermittent problem. Being such a rare clinical entity and a difficult condition to diagnose, it is commonly diagnosed at the time of surgery or even at autopsy.We present the case of an 82-year-old independent female with a past medical history of hiatal hernia, who came to the emergency department with hematemesis and severe epigastric pain. An abdominal CT scan revealed an organoaxial stomach volvulus within the intrathoracic cavity.After initial treatment with gastric decompression, IV fluids and proton pump inhibitors, the patient was informed that the surgical intervention would be the only definitive curative treatment for her condition and denied the procedure. She was then discharged after clinical and analytical improvement. She was offered a conservative treatment and follow up by the internal medicine team. After a few months, the patient reported moderate improvement of her symptoms and less episodes of epigastric pain. She was pleased with the conservative management and denied any surgical or invasive procedures. A proximity contact was established with the family doctor, which she maintains.This case report is proof that rare entities can happen to patients presenting common symptoms and better resolutions come from multidisciplinary approaches.

S2918 Giant Paraesophageal Hernia and Gastric Volvulus: An Uncommon Etiology of Vomiting and Upper Gastrointestinal Bleeding

INTRODUCTION: Paraesophageal hiatal hernia is a rare type of hiatal hernia, which occurs mostly in the elderly population after the age of 70, and accounts for less than 5% of all hiatal hernias. Here we report a rare case of a large paraesophageal hiatal hernia and gastric volvulus as an uncommon cause of vomiting and upper gastrointestinal bleeding. CASE DESCRIPTION/METHODS: A 46-year-old female with a past medical history of anemia and GERD presents with one day history of coffee ground emesis and melena. She has no history of previous gastrointestinal bleeding and denies NSAID use. She has been off PPI agents for one year due to the improvement of acid reflux disease after weight loss of 40 lbs. Etiology of anemia was not found during the previous GI workup including an upper endoscopy completed locally. Upon presentation, her hemoglobin was checked low at 9.3 g/dl from her baseline of 11.0 g/dl. She underwent a repeat upper endoscopy which revealed a large paraesophageal hernia (7 cm) with multiple linear erosions/ulcerations, suggestive of Cameron's lesions. The insufflation of the stomach was abnormal, with a distorted antrum located at an eccentric angle concerning for gastric volvulus. Further workup with computerized tomography (CT) scan of the chest and abdomen showed findings of a large type 3 hiatal hernia with organoaxial volvulus, and no evidence of ischemia or obstruction. She subsequently underwent laparoscopic repair of her paraesophageal hernia and Nissen fundoplication with resolution of anemia after the surgery. DISCUSSION: Paraesophageal hernia with gastric volvulus is a rare entity that can manifest with vomiting due to partial or complete gastric outlet obstruction, and gastrointestinal bleeding due to mucosal ischemia or Cameron's lesions. It is critical for gastroenterologists to recognize paraesophageal hiatal hernias during upper endoscopy evaluation, due to its association with gastric volvulus leading to incarceration and life-threatening strangulation. Emergency surgery is required for acute ischemic gastric volvulus. Otherwise, elective surgery can be offered to symptomatic patients and laparoscopic surgery is the mainstay of treatment approaches.Figure 1.: Giant Paraesophageal hiatal hernia: Retroflexion (A) and forward view (B) revealed giant hiatal hernia with Cameron lesions. C: Chest/abdominal CT confirmed large type 3 paraesophageal hernia with gastric volvulus.

Intrathoracic sleeve gastrectomy migration with gastric volvulus treated with laparoscopic repair and conversion to gastric bypass.

A 43 years old female with laparoscopic sleeve gastrectomy (SG) and an ‘anterior’ hiatal hernia repair 11 years ago, presented with 3 years history dysphagia and heartburn. Upper gastrointestinal barium showed an almost complete intrathoracic migration of the SG with a partial organoaxial volvulus. Upper endoscopy revealed a 10 cm hiatal hernia with grade B esophagitis. Laparoscopic revision surgery with reduction of the gastric sleeve, standard posterior hiatal hernia repair, resection of the narrowed remnant of the SG and conversion to a gastric bypass was performed. No postoperative complications occurred. The patient is asymptomatic at 2 years of follow-up. We present the technical standards for the management and discuss the suspected pathophysiology of this rare but challenging condition.

Üst Gastrointestinal Sistem Floroskopi Yapılan Pediatrik Hastalarda Gastroözofageal Reflü Tanısını Etkileyen Faktörler

Objective: The aim of this study was to evaluate the results of upper gastrointestinal fluoroscopy in infants and children and to investigate factors affecting results and the diagnosis of gastroesophageal reflux (GER). Material and Methods: Patients between the ages of 1 month and 18 years who underwent upper gastrointestinal fluoroscopy at the Radiology Department of Dr. Sami Ulus Research and Training Hospital between January 1, 2018 and December 31, 2018 were included in the study. The files of the patients were reviewed retrospectively. Results: Of the 76 patients who underwent upper gastrointestinal fluoroscopy, 46.1% were male and median age was 10 months. Among these, 2.6% (n=2) were diagnosed with mild GER, 18.4% (n=14) with moderate GER, and 38.2% (n=29) with severe GER. The accompanying anatomic pathologies were: malrotation (5.3%), operated esophageal atresia and diaphragmatic hernia (2.6%), organoaxial volvulus and prepyloric web (1.3%). Reasons of requesting upper gastrointestinal fluoroscopy were persistent vomiting in 40.8% (n=31), intermittent vomiting in 10.5% (n=8), and coughing in 11.8% (n=9). The most common accompanying pathologies were prematurity and growth retardation in 6.6% (n=5). 74.4% of those younger than 1 year of age were diagnosed with GER, while this percentage was 39.4% in those aged 1 year or older. The incidence of GER in patients younger than 1 year of age was found to be significantly higher (p=0.002). GER was present in 74.2% (n=23) of patients who had persistent vomiting, while it was present in 48.9% (n=22) of patients who underwent upper gastrointestinal fluoroscopy for other reasons. This difference was also statistically significant (p=0.027). Conclusion: In cases where gastroesophageal reflux disease is suspected, if the patient is younger than 1 year of age or has persistent vomiting, upper gastrointestinal fluoroscopy may be useful to confirm the diagnosis. However, anatomical disorder can be detected in very few of the recommended UGF. From this point of view, it would be more appropriate for clinicians to recommend UGF in more suitable cases considering radiation related risks and procedure difficulties.

2763 A Case of Intermittent Organo-axial Gastric Volvulus

INTRODUCTION: Gastric volvulus is a rare clinical entity defined as twisting of the stomach along its long or short axis leading to gastric outlet obstruction (GOO). Commonly symptoms are acute and include retching, abdominal pain, and vomiting. Chronic intermittent manifestations of this entity constitute a diagnostic challenge as conclusive findings in imaging are only present during symptomatic periods and due to the intermittent nature of the disorder, a volvulus may spontaneously resolve before imaging studies are performed. Herein we illustrate a rare case of an intermittent organo-axial gastric volvulus that responded to conservative measures. CASE DESCRIPTION/METHODS: A 92-year-old female presented with intermittent epigastric pain and food intolerance of a few weeks duration. She reported dysphagia one year prior to presentation. Upper gastrointestinal (UGI) series showed gastric organo-axial rotation with no obstruction. Symptoms resolved at that time without any intervention. Physical examination revealed epigastric tenderness. Vitals and laboratory tests were unremarkable. UGI series showed a large para-esophageal hernia, an intrathoracic stomach with a gastric organo-axial rotation and partial obstruction at the level of gastroduodenal junction [Figures 1 and 2]. A contrast computed tomography (CT) scan of abdomen confirmed the same findings [Figure 3]. Endoscopic as well as surgical gastropexy were offered but the patient refused any intervention in view of her poor functional status. She was managed conservatively with intravenous fluids and bowel rest and was discharged 5 days later. DISCUSSION: Gastric volvulus was first described in 1866 as a torsion of the stomach around its short or long axis. Based on the axis of rotation, it was classified into organo-axial, mesentero-axial or combined. Organo-axial volvulus is common in adults, constitutes about 59% of cases and peaks after the 5th decade of life. It is mainly seen in the context of diaphragmatic abnormalities such as para-esophageal Hiatal hernias and diaphragmatic eventration. Diagnosis is challenging due to non-specific presenting symptoms. Contrast CT of abdomen and UGI series are gold standard diagnostic modalities. Endoscopic and surgical gastropexy is the mainstay of therapy. Heightened awareness is warranted in patients presenting with GOO in the setting of UGI tract anatomical abnormalities, since delayed diagnosis and management may lead to life-threatening complications and mortality rates up to 50%.

2689 Gastric Volvulus: A Difficult Situation of Diagnosis and Management

INTRODUCTION: Gastric volvulus is a rare entity defined as an abnormal rotation of the stomach around its short or long axis leading to variable degrees of gastric inlet and outlet obstruction. Organoaxial and mesentericoaxial volvulus are distinguished according to the direction of rotation. A rotation of more than 180 degrees can cause strangulation, necrosis and finally perforation. CASE DESCRIPTION/METHODS: We present the case of a 43-year-old female that complained of severe abdominal pain, nausea and vomiting for 2 days after eating a large meal. She did not have any flatus or bowel movements in the last 48 hours. On admission in our clinic, biological findings included an inflammatory syndrome, an anaemic syndrome and hypokalaemia. The radiology images highlighted a high air-fluid level in the chest and the ultrasound examination showed a significant stomach fluid distension. The upper digestive endoscopy revealed multiple ulcerated lesions and stasis fluid at the gastric angle, a point from which exploration could no longer be continued. Computed tomography (CT) of the abdomen and pelvis showed a dilatation of the stomach and the displacement of the antrum above the gastroesophageal junction; the stomach appeared upside-down with the antrum and pylorus superior to the fundus and proximal body. Based on clinical manifestations, biological results, radiograph images, ultrasounds, upper endoscopy and CT scan, the patient was diagnosed with high occlusion via congenital organo-axial volvulus. Initial management was nasogastric decompression to decrease the intragastric pressure. The patient was transferred to the Surgery Department, where he underwent a laparotomy which confirmed an organoaxial volvulus at the level of the antrum and body of the stomach. Gastropexy was implemented and the stomach fixed to the posterior abdominal wall to prevent recurrence. Postoperative recovery was uneventful and the patient returned to his rehabilitation facility on the fourth post-operative day. DISCUSSION: We present this case because it is an uncommon life-threatening disease. Given its rarity and unusual presentation, the clinical index of suspicion is always low. Diagnosis of gastric volvulus is challenging due to the non-specificity of the symptoms and rarity of the condition. Early diagnosis and treatment will reduce the risk of developing chronic gastric volvulus to acute gastric volvulus.

3143 Gastric Volvulus: Coffee Ground Emesis and NGT Resistance in an Otherwise Asymptomatic Elderly Man

INTRODUCTION: Adult gastric volvulus is generally diagnosed by the symptoms of abdominal or chest pain. Acute presentation include symptoms of pain, vomiting, and failure of placement of naso-gastric tube (NGT) also known as Borchardt Triad. Severity of sequelae is dependent on significance of the rotation with rotations of >180° causing possibly outlet obstruction, strangulation, necrosis leading to perforation and severe sepsis leading to death. CASE DESCRIPTION/METHODS: A 92 year old gentleman is admitted for UTI related sepsis and started on antibiotics. On day 8 of his admission, patient complained of abdominal epigastric pain and had two episodes of dark red colored particulate emesis. Hemoglobin was stable and physical exam showed mild distention and slight tenderness on palpation but was otherwise nonsignificant. Multiple attempts at nasogastric tube placement were difficult due to resistance during insertion at below oro-pharyngeal levels. Abdominal CT scan (Figures 2 and 3) was completed showing left diaphragmatic hernia with herniation of the stomach with upside down stomach is noted with partial gastric outlet obstruction with the distended stomach, indicating organo-axial volvulus. This was not obviously noted in the admission chest X-ray (Figure 1). Given requirement for gastrostomy, patient was transferred to hospital of their choice where he subsequently received surgery and was discharged 4 months later. DISCUSSION: The diagnosis of gastric volvulus in this patient was not initially apparent as his abdominal pain complaints were very mild, his labs were normal and stable, and his initial admission was for sepsis. It was primarily the resistance in the placement of the NGT and the coffee-ground emesis that raised suspicion and prompted the CT imaging scan, which revealed the diagnosis. Therefore, it is important to have medical professionals remain cognizant of the possibility of the diagnosis of gastric volvulus, no matter how rare, in an elderly patient with resistance to NGT placement. And although the Borchardt triad is apparent in 75% of acute gastric volvulus cases, it is important to remember that up to 25% of patients do not present classically, and therefore gastric volvulus should not be excluded as a possible diagnosis.

2687 A Rare Case of Organoaxial Volvulus of the Stomach

INTRODUCTION: Gastric volvulus is an uncommon and potentially life-threatening clinical entity characterized by rotation of the stomach along its long or short axis provoking variable degrees of gastric outlet obstruction. Clinical presentation varies between acute and chronic volvulus. Here we present a rare case of chronic organoaxial volvulus presenting with dysphagia. CASE DESCRIPTION/METHODS: The patient is an 87 year old male with a medical history of hypertension, obstructive sleep apena, multi-nodular goiter (with thyroid resection resulting in vocal cord paralysis) who was referred to the gastroenterology clinic for dysphagia. The patient states he had dysphagia to solids for one year. The patient denied associated nausea, vomiting, hematemesis, hematochezia, constipation or unintended weight loss. Complete blood count and comprehensive metabolic panel at that time were unremarkable. Physical exam was also unremarkable. Given his symptoms a barium swallow was ordered to further evaluate his gastrointestinal tract. This was done and showed no evidence of esophageal obstruction or esophageal mass, but did incidentally find organoaxial rotation of the stomach. The patient was scheduled to undergo upper esophagogastroduodenoscopy, but was non-compliant with the appointment and lost to follow up. DISCUSSION: Acute gastric volvulus usually presents with sudden onset abdominal or chest pain, severe retching with occasional vomiting, and epigastric distention. Chronic gastric volvulus on the in contrast can present with a complete absence of symptoms to non- specific symptoms, such as abdominal pain, dyspepsia, dysphagia, acid reflux, nocturnal cough, hiccups, non-bilious vomiting, weight loss, and anemia. Diagnosis of gastric volvulus is conventionally achieved with chest radiograph, upper barium studies or CT- scan. Regardging treatment of acute symptomatic gastric volvulus, nasogastric decompression is usually the first step, followed by surgery. Some patients at high risk for surgery, mainly elderly, can also be treated endoscopically with adequate decompression and reduction of the stomach and placement of a gastrostomy tube to gastropexy the stomach to the abdominal wall.

CT of Gastric Volvulus: Interobserver Reliability, Radiologists' Accuracy, and Imaging Findings.

The objective of this study was to identify CT findings and determine interobserver reliability of surgically proven gastric volvulus. This single-center retrospective study included 30 patients (21 women, nine men; mean age, 73 years old) with surgically proven gastric volvulus who underwent preoperative CT and 31 age- and sex-matched control subjects (21 women, nine men; mean age, 74 years old) with large hiatal hernias who were imaged for reasons other than abdominal pain. Two blinded radiologists reviewed the CT images and recorded findings of organoaxial and mesenteroaxial gastric volvulus and ischemia. Interobserver reliability, reader accuracy, sensitivity, specificity, and likelihood ratios of each CT finding were calculated. The radiologists were overall 90% accurate (55/61; six false-negatives per reader) in identifying gastric volvulus. Interobserver agreement was substantial (κ = 0.71) for identifying the presence or absence of gastric volvulus. Agreement for most CT findings of gastric volvulus (11/14, 79%) was excellent (5/14, 36%) or substantial (6/14, 43%); the remaining findings showed moderate agreement (3/14, 21%). The most frequent and sensitive CT findings of volvulus with high positive likelihood ratios were stenosis at the hernia neck (reader 1, sensitivity = 80%, positive likelihood ratio = 26.66; reader 2, sensitivity = 77%, positive likelihood ratio = 12.83) and transition point at the pylorus (reader 1, sensitivity = 80%, positive likelihood ratio = 17; reader 2, sensitivity = 70%, positive likelihood ratio = 15). The presence of perigastric fluid or a pleural effusion were significantly more frequent in patients with ischemia at surgical pathology (p < 0.05 in all comparisons, both radiologists). In our series, CT showed substantial interobserver agreement and fair accuracy in identifying the presence of gastric volvulus.

VS02.09: LAPAROSCOPIC REPAIR OF RECURRENT TYPE IV PARAESOPHAGEAL HERNIA WITH COLLIS GASTROPLASTY

Abstract Description Laparoscopic Repair of Recurrent Type IV Hiatal Hernia with Collis Gastroplasty In this case, we present a laparoscopic repair of a large, recurrent type four paraesophageal hernia with a Collis Gastroplasty. The patient presented 4 months after repair of an initial hernia at a separate facility with primary hiatal closure without an anti-reflux procedure. Intra-operatively, there was a giant type IV hernia with the transverse colon and the majority of the stomach in the right chest with an organ-oaxial volvulus. The colon and omentum were easily reducible, but the stomach was densely adherent within the right chest. After extensive dissection, the stomach was able to be reduced into the abdomen, but only two centimeters of intra-abdominal esophagus remained and a Collis gastroplasty was performed. A Nissen fundoplication was then performed at the end of the case. This case demonstrates three unique findings. The first is the short time to recurrence after a prior repair without any establishment of an anti-reflux barrier. The second is the unusual hernia with the majority of the stomach located in the right chest. Finally, this video demonstrates the technique of a laparoscopic Collis gastroplasty with a wedge fundectomy technique given the intra-operative findings of a short esophagus. This technique is a reproducible approach that creates a neo-esophagus that can be considered when there is axial tension after full mobilization of the esophagus. Identification of optimal location for stapler placement is facilitated by concurrent laparoscopy with endoscopic identification of the gastroesophageal junction. Disclosure All authors have declared no conflicts of interest.