Case Study by Natalie DeWitte 1 ; Patrick A . Dolan , MS , MD , FACS 2 ; Zachary Larrimer , MD , FACS 2
Gastric Volvulus With Complete Gastric Obstruction in Suspected Non-ST-Elevation Myocardial Infarction Patient
Abstract
Gastric volvulus is the abnormal rotation of the stomach causing varying degrees of outlet obstruction . We discuss here the case of a 69-year-old woman presenting with chest and abdominal pain and nausea and vomiting , who was being worked up for a suspected Non-ST elevation myocardial infarction ( NSTEMI ). Acute gastric volvulus was suspected on chest x-ray . CT of abdomen confirmed the diagnosis , showing a hiatal hernia with organoaxial volvulus and gastric outlet obstruction . Laparoscopic repair was performed with reduction of the stomach , crural repair , Nissen fundoplication , and gastropexy with G tube placement . Patient developed an acute ischemic stroke postoperatively and was transferred for neurointervention .
Introduction
Gastric volvulus is a malrotation of the stomach along its long or short axis , which can lead to varying degrees of gastric outlet obstruction . 1 , 3 Generally , a rotation of more than 180 degrees , if not recognized , will lead to strangulation and necrosis with perforation of the stomach 4 . In addition , there are certain anatomical abnormalities that will increase patient risk for gastric volvulus , such as abnormalities of the gastric ligaments . The most likely cause of gastric
volvulus in adults , however , is the presence of a hiatal hernia , specifically a paraesophageal hernia . 2
Gastric volvulus will commonly present with chest and epigastric pain associated with vomiting . Historically , these symptoms may be acute or chronic and often intermittent . As such , an initial workup that includes a history of chest pain often suggests a cardiac etiology . Failure to consider the diagnosis of acute gastric volvulus with complete obstruction may delay definitive treatment and increase patient morbidity and mortality .
Case Report
This case study describes a 69-year-old woman with a known symptomatic hiatal hernia who presented to an outside medical facility with chest and abdominal pain , nausea and vomiting . Her past medical history was significant for hypertension and gastroesophageal reflux disease , with
Figure 1 . Chest X ray showing large hiatal hernia , CT was suggested to confirm gastric volvulus
1
Medical Student , Arkansas College of Osteopathic Medicine , Fort Smith , Ark .
2
Department of General Surgery Rotations , CHI St . Vincent , Hot Springs , Ark .
biopsy proven esophagitis . There was no evidence of metaplasia on the biopsy . Her chest film showed a large hiatal hernia with a significant portion of her stomach in her chest . Her EKG showed t wave changes in her inferior leads . Troponin lab results were not available . The patient received IV fluids and electrolyte replacement . Oxygen was administered , and her chest pain and nausea were successfully treated . The patient was then transferred to our facility with the diagnosis of an NSTEMI .
The patient was evaluated in our emergency room . She was alert and had no specific complaints other than mild nausea . Her blood pressure was 110 / 75 , with an irregular pulse . Her previous studies were reviewed . Her chest x-ray suggested a gastric volvulus present with gastric outlet obstruction ( Figure 1 ). A second EKG revealed atrial fibrillation with a rapid ventricular rate . Her physical exam revealed
Figure 2 . CT of Abdomen and Pelvis showing large hiatal hernia with gastric volvulus .
184 • The Journal of the Arkansas Medical Society www . ArkMed . org