mild abdominal distension with mild epigastric tenderness and no peritoneal signs . A nasogastric tube could not be passed . Lab work was unremarkable ; however , arterial blood gas revealed a metabolic alkalosis . Finally , a CT scan of the abdomen and pelvis was done , which confirmed the diagnosis of a large hiatal hernia with gastric volvulus as the etiology of her gastric outlet obstruction ( Figure 2 ). The patient was medically optimized and prepared for surgery . Intraoperatively , organoaxial gastric volvulus was found , with herniation of the stomach into the left chest . The hernia was reduced , and the volvulus corrected . There was no evidence of gastric ischemia . A 360-degree posterior fundoplication was performed with crural repair . A gastropexy via placement of a gastrostomy tube completed the procedure .
Discussion
The majority of cases of gastric volvulus present in the elderly , beginning in the fifth decade . 2 , 3 There is no association with a particular sex or race . Risk factors , other than age , include diaphragmatic abnormalities such as hiatal hernia , eventration , and sequelae of phrenic nerve paralysis . Certain musculoskeletal problems , such as kyphoscoliosis , also increase the risk . In general , gastric volvulus is characterized as primary or secondary . Primary or idiopathic is due to abnormalities of gastric ligaments responsible for gastric fixation . This failure of gastric fixation specifically relates to agenesis , elongation , or disruption of those ligaments . The symptoms associated with this are usually chronic . Secondary gastric volvulus is associated with diaphragmatic abnormalities , commonly a paraesophageal hernia and other hiatal hernias . 2
Acute gastric volvulus presents with pain in the abdomen or lower chest and is associated with nausea and vomiting . The combination of abdominal pain , vomiting , and the inability to pass a nasogastric tube is known as Borchardt ’ s triad . Seventy percent of patients present with this triad . 1 , 2 With complete gastric obstruction , the stomach is usually dilated with air fluid levels , best documented on plain films and CT scan . Other physical findings at presentation include hypotension , tachypnea , abdominal distension , and epigastric tenderness . Gastric sounds may be auscultated in the chest . Signs of peritonitis are a late finding . Chronic gastric volvulus may have vague and intermittent symptoms . 1 Those symptoms are abdominal discomfort , bloating , dysphagia , retching , early satiety , and heartburn . It is often associated with a gastric ulcer . The diagnosis of chronic gastric volvulus is more difficult and may require additional testing such as an upper gastrointestinal series and endoscopy .
The treatment of acute gastric volvulus begins with attempting to pass an NG tube and decompress the stomach . Likewise , endoscopy may be used . Resuscitation is usually needed to include fluid and electrolyte management . Broad spectrum antibiotics are begun . Surgery is the definitive treatment , and emergency surgery is needed if the stomach cannot be decompressed . 5 In general , surgery consists of volvulus reduction , crural repair , and an antireflux procedure .
Finally , because of the increased risk of gastric volvulus and ulceration in patients with a symptomatic paraesophageal hernia , elective repair should be considered . 5 , 6 Whether this should be done in the asymptomatic patient is not as clear .
Conclusion
Gastric volvulus is a rare occurrence and the correct diagnosis is often difficult . Patient outcomes are generally poor without early recognition . This is demonstrated when a cardiac etiology is the initial diagnosis , even in the presence of a large hiatal hernia . The diagnosis of gastric volvulus often suggests a cardiac etiology because gastric rotation can be intermittent in nature and mimic angina historically . Ultimately , the physical findings of epigastric tenderness , radiographic findings of a large gastric air fluid level in the presence of a hiatal hernia , followed by CT scanning usually confirm the diagnosis . With acute gastric volvulus , emergent surgical correction is the definitive treatment .
In this specific case , the patient had a large hiatal hernia with reflux symptoms treated medically . There are times during patient follow up that elective repair of the hiatal hernia should be considered . This is especially true in the case of a paraesophageal hernia . Gastric volvulus , although not common , should be considered in the differential diagnosis of a patient presenting with chest pain and abdominal symptoms , especially in the presence of gastric outlet obstruction associated with a large hiatal hernia .
References
1 . Rashid F , Thangarajah T , Mulvey D , et al . A review article on gastric volvulus : a challenge to diagnosis and management . Int J Surg 2010 ; 8:18 .
2 . Chau B , Duffels . Gastric volvulus . Emerg Med J 2007 ; 24:446 .
3 . Wu MH , Chang YC , Wu CH , et al . Acute gastric volvulus : a rare but real surgical emergency . Am J Emerg Med 2010 ; 28:118 . e5 .
4 . Shivanand G , Seema S , Srivastava DN , et al . Gastric volvulus : acute and chronic presentation . Clin Imaging 2003 ; 27:265 .
5 . Light D , Links D , Griffin M . The threatened stomach : management of the acute gastric volvulus . Surg Endosc 2016 ; 30:1847 .
6 . Channer LT , Squires GT , Price PD . Laparoscopic repair of gastric volvulus . JSLS 2000 ; 4:225 .
185 • The Journal of the Arkansas Medical Society www . ArkMed . org