BY FAHAD SHAH & AHMED RAZIUDDIN, MD
A 68-year-old woman presented with acute abdominal pain that had started three hours earlier. She said she had constant upper abdominal pain that was sharp and stabbing, and she rated her pain as 8/10.
The patient said the pain did not radiate, and she was clearly in acute distress. She reported that her last meal had been four hours before and that she was nauseated and had had three to four episodes of dry heaves.
She had no other concerning symptoms, and her pain was unaffected by eating, drinking, or position. She had a paraesophageal rolling hiatal hernia and was aware of her chronic condition, but had not sought treatment because it was not overtly symptomatic besides mild GERD and indigestion.
She had a blood pressure of 156/100 mm Hg, a pulse of 70 bpm, a respiratory rate of 20 bpm, and an oxygen saturation of 97% on room air. Her pain was above the umbilical region, and she was in a left lateral decubitus position to cope with the pain. The examination revealed upper abdominal tenderness, minimal distention, and normal bowel sounds without guarding or rebound tenderness.
She was given ondansetron 4 mg, morphine 4 mg, and IV fluids. The patient's blood panel showed a low RBC count of 4.15 m/uL, a hemoglobin of 11.7 g/dL, and a slightly decreased hematocrit of 36.4%. Her neutrophils were high at 82.5%, lymphocytes were low at 14.5%, and glucose was elevated at 162 mg/dL. Her lactic acid and lipase were elevated at 2.4 mmol/L and 127 u/L, respectively.
A CT of the abdomen and pelvis revealed mild subsegmental atelectasis in the lower pulmonary lobes, bilaterally bordering a type IV giant paraoesophageal hiatal hernia with mesenteroaxial gastric volvulus. The stomach was practically in the thoracic cavity. The gastroesophageal junction and gastric fundus were above the left hemidiaphragm level with the latter also distended by fluids. The gastric antrum was decompressed and transverse craniocaudally through the left hemidiaphragm, while the gastroduodenal junction was decompressed and displaced to the left hemidiaphragm level. The gastric body appeared distended by fluid and located below and above the left hemidiaphragm. A CT showed a left hemidiaphragmatic defect measuring 7x5.5 cm. The patient subsequently underwent emergent exploratory laparotomy for volvulus reduction and diaphragmatic defect repair.
Left sagittal CT demonstrates antrum at the level of gastroesophageal junction.
Easily Misdiagnosed and Life-threatening
Acute gastric volvulus is rare, traditionally presenting with Borchardt's triad of severe epigastric pain and distension, intractable retching without vomiting, and the inability to pass a nasogastric tube. It has limited association with race or sex, but it is often associated with age, most commonly in those in the fifth decade of life. It can be linked to paraoesophageal hiatal hernias or other anatomical gastrointestinal abnormalities. It is crucial to identify and manage the condition early so surgical intervention can be made. Undiagnosed acute gastric volvulus can lead to ischemia, tissue necrosis, and death. Borchardt's triad is present in 70 percent of cases, but early recognition can be difficult because patients may not present with those classic symptoms. It can also be mistaken for more common abdominal pain disorders such as biliary disease, peptic ulcer disease, and pancreatitis. (Int J Surg Case Rep. 2014;5:731, http://bit.ly/2kBFZ7p; Emerg Med J. 2007;24:446, http://bit.ly/2kSu4lT.)
A rare form of gastric volvulus is caused by the abnormal rotation of the stomach by more than 180 degrees with a comorbid paraoesophageal rolling hiatal hernia. Gastric volvulus creates a closed-loop obstruction that can lead to strangulation and ultimately necrosis and tissue death. The gastroesophageal junction remains in place in paraoesophageal hiatal hernia, but part of the stomach herniates from the abdomen into the chest. The herniation occurs in the esophageal hiatus, which lies adjacent to the gastroesophageal junction. These account for five percent of hiatal hernias. It is important to recognize the symptoms of gastric volvulus early because they are nonspecific and can be misdiagnosed and life-threatening.
Symptoms occur due to abnormal rotations of the stomach by more than 180 degrees. Rotations can be classified into two types: organoaxial, which is more common and results from twisting along the luminal axis of the stomach that connects the cardia and the pylorus, and mesenteroaxial, which results from twisting perpendicular to the luminal axis, is from lesser to greater curvature, and is seen in 29 percent of cases. Patients can present with a combination of the two, but that is the least common type. (Biomed Imaging Interv J. 2009;5:e18; http://bit.ly/2mbXj32.)
A diagnosis of gastric volvulus is often delayed because of nonspecific symptoms. Patients might not always be symptomatic, but hiatal hernia with retching after treatment with antiemetic should prompt investigation for gastric volvulus. (Eur Radiol. 2014;24:3115.)
Plain radiographic findings will show retrocardiac air-fluid level with intrathoracic upside-down stomach. A barium study can also be used, and will show the degree of obstruction by determining the flow rate of oral contrast into the duodenum. Nonetheless, CT is the modality of choice in acute settings because x-ray and barium might not be feasible in an acutely symptomatic patient. (Biomed Imaging Interv J. 2009;5:e18, http://bit.ly/2mbXj32; Eur Radiol. 2014;24:3115.)
Mr. Shah is a fourth-year medical student at the University of Medicine & Health Sciences in St. Kitts. Dr. Raziuddin is an emergency physician at Weiss Memorial Hospital in Chicago.