INTRODUCTION:
Gastric volvulus is a rare cause of gastric outlet obstruction that if not recognized early can lead to ischemia, necrosis and death. Organoaxial is the most common type and is seen with secondary anatomic defects i.e. paraesophageal hernias, diaphragmatic hernias and diaphragm eventrations. It occurs in 60% of cases with 30% risk of strangulation. Risk factors include age >50 years, secondary anatomic defects, phrenic nerve paralysis and structural abnormalities of the stomach/spleen. Symptoms include abdominal pain, chest pain, retching and/or vomiting. Misdiagnosis occurs because of its nonspecific presentation. We describe a case of a patient who was admitted for suspect acute coronary syndrome and found to have an acute gastric volvulus.
CASE DESCRIPTION/METHODS:
75 yo m with pmh of HTN, who p/w sudden onset neck pain radiating to L arm, with N/V during activity. He denied chest pain, SOB or diaphoresis. Vitals were T 98 F, HR 85, BP 156/69, and RR 18. On exam pt had decreased breath sounds LLL, NT abdomen, and left paraspinal neck tenderness. Pertinent labs: WBC: 11. Chemistry with hypokalemia. Normal troponins. CXR showed L hemidiaphragm elevation and hiatal hernia. Neck imaging was normal. EKG was normal without st changes. Overnight the pt became altered with intractable neck pain, nausea and vomiting. Repeat cxr showed widened mediastinum. A stat CTA chest/abd/pelvis showed organoaxial gastric volvulus with fluid filled esophagus. EGD abnormalities lead to an ex-lap with gastrostomy, gastropexy and volvulus reduction. Pt did well and went to a rehab facility.
DISCUSSION:
Gastric volvulus often manifests with abdominal pain in addition to nausea and vomiting rather than neck or chest pain. There have been reports of cases mimicking acute coronary syndrome. Intractable neck pain without abdominal pain is an extremely rare phenomenon in patients with acute gastric volvulus. In order to establish a diagnosis in our patient, a high index of suspicion was imperative for identifying an atypical presentation of acute gastric volvulus. This was illustrated by ordering a CT chest as soon as he became more ill-appearing. In retrospect, the intractable neck pain could have been considered as referred pain from the elevated left hemidiaphragm in the setting of a known hiatal hernia. Literature search was heterogeneous and scarce. Thus, we recommend high index of suspicion for acute gastric volvulus in the setting of intractable neck pain in order to intervene earlier and avoid worse outcomes.
