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VOMITING WITH A TWIST: A CASE OF GASTRIC VOLVULUS
M Puglia, JK Marshall, C Ward
Departments of Medicine and Surgery, McMaster University, Hamilton, ON
Common causes of acute gastrointestinal obstruction include post-operative adhesions, obstructing masses and incarcerated hernias. However the list of potential causes is long. Unless clinicians maintain a high index of suspicion, the diagnosis of rare causes of intestinal obstruction may be delayed or even missed.
We report a case of intestinal obstruction caused by an organoaxial gastric volvulus in a 76 year-old male patient with a pre-existing paraesophageal hiatus hernia. He presented with acute abdominal pain, vomiting and minor coffee-ground emesis. Signs of acute peritonitis were absent. Chest radiography revealed a large hiatus hernia in the retrocardiac space. There was no evidence of obstruction or free air on abdominal radiographs. The patient underwent esophagogastroduodenoscopy (EGD) because of the history of coffee-ground emesis. A diagnosis of gastric volvulus was suggested when an endoscope could not be passed beyond the stomach. A CT scan revealed a large paraesophageal hiatal hernia with organoaxial gastric volvulus, confirming the diagnosis. He was brought urgently to the operating room where an open laparotomy with reduction of the volvulus, closure of the hiatal defect, anterior gastropexy (to prevent future rotation) and Nissen fundoplication were performed successfully.
Acute gastric volvulus is a rare but potentially life-threatening event. First described by Berti in 1866, gastric volvulus is a malrotation of the stomach by 180 degrees to create a closed loop obstruction. Mortality from acute gastric volvulus is approximately 50%. The classic clinical picture is that of intestinal obstruction (crampy abdominal pain and vomiting), often with peritonitis and/or hemodynamic instability. Gastric volvulus often occurs in the setting of a diaphragmatic defect, such as a paraesophageal hernia.
This case demonstrates that, despite the absence of classical peritoneal findings, an acute gastric volvulus should be considered in the differential diagnosis of any patient who presents with symptoms of gastrointestinal obstruction and particularly in those with pre-existing paraesophageal hernias. Using this case as an illustration, the epidemiology, pathophysiology, clinical presentation, diagnosis and treatment of this rare and potentially lethal cause of intestinal obstruction will be discussed.