Journal Article

As the Stomach Turns: A Case of Chronic Gastric Volvulus

Young, Patrick E, Junga, Zachary, Francis, Jonathan

2018

Overview

Introduction Gastric volvulus is a rare condition with an unknown incidence and prevalence. Mortality rates may be as high as 50%. Some cases may be intermittent or undiagnosed.Case Description A 96 year-old male with a history of coronary artery disease status post drug-eluting stents on aspirin and clopidogrel presented to the hospital with 3 episodes of nausea and bloody emesis. The patient was at his clinical baseline other than a mild decrease in appetite. Labs were normal except for an acute kidney injury. He was admitted to intensive care, put on a continuous proton pump inhibitor infusion, and resuscitated. Aspirin was continued and clopidogrel was held. An EGD demonstrated diffuse gastropathy with heme staining in the gastric body which was likely the source of patient's hematemesis. Of note, upon passing into the stomach, a large paraesophageal hernia with volvulus of the stomach was appreciated making it difficult to locate the antrum. In retroflexion with a biopsy forceps to stiffen the scope and abdominal pressure, we were able to position the scope tip into the thoracic component of the hernia which allowed us then to navigate into the gastric antrum and complete the examination. The hematemesis resolved and the patient was started on a diet without issue. A CT scan the following day confirmed the presence of a paraesophageal hernia and volvulus though whether it was organoaxial versus mesenteroaxial was not clear. A prior chest CT scan from 2 years prior showed the same findings. Due to patient's age, high surgical risk, and chronic nature of the volvulus, the patient elected for observation rather than surgery. He continued to do well and was discharged home 7 days later. Discussion Acute gastric volvulus is a rare but important diagnosis as rapid definitive surgical management decreases mortality. In this case, it is possible that the patient's chronic volvulus acutely worsened causing ischemia and bleeding which led to the hematemesis. The acute aspect of the volvulus may then have resolved on its own. It is also possible that his bleeding gastropathy was unrelated. Regardless, this is a case that demonstrates the importance of diagnosis and establishing chronicity in managing gastric volvulus.

• Publisher: Wolters Kluwer Health Medical Research, Lippincott Williams & Wilkins
• Subject: Cardiovascular disease / Gastroenterology / Hematemesis / Hernias / Medical imaging / Mortality