Gastric Volvulus: Bang Chau, Susan Dufel

446 Emergency casebook
shown that dysphagia, epigastric pain

Gastric volvulus and chest pain occur 29% of the time
individually.3
Bang Chau, Susan Dufel Symptoms are brought on by the
rotation of the stomach by more than
180˚. Rotation of the stomach along the
long axis extending from the gastro-
Gastric volvulus is a rare disease with an unknown incidence. Unless it stays in the oesophageal junction to the pylorus
back of the diagnostician’s mind, diagnosis of gastric volvulus, which can have is termed mesenteroaxial rotation.
significant morbidity and mortality associated with it, can be easily missed. Unstable Organoaxial gastric volvulus results from
vital signs and distressed appearance are not always present, as in textbook cases. the rotation of the stomach around the
The presence of a hiatal hernia with persistent vomiting despite initial antiemetic axis that bisects the lesser and greater
treatment should trigger one to think of gastric volvulus, despite the patient appearing curvatures of the stomach (table 1).4 The
very stable. With the advent of CT and laparoscopic surgery, the gold standards for organoaxial type constitutes about 59%
diagnosing and treating this disease are ever evolving. of all gastric volvulus, whereas 29% are
mesenteroaxial (fig 2). The remaining
CASE PRESENTATION DISCUSSION 12% are a mixture of both.5
Gastric volvulus is a rare entity that The aetiology of the rotation is either
An 82-year-old female with a history of primary or secondary. ‘‘Primary’’ refers to
can be elusive to diagnose. The inci-
hiatal hernia, peptic ulcer disease and the absence of diaphragmatic defects or
dence is unknown, due to the existence
asthma presented to the emergency of a chronic form of gastric volvuli. intra-abdominal abnormality causing the
department with an acute onset of The peak age group of incidence is volvulus. Laxity of the ligaments which
sharp epigastric pain for 4–5 h without in the fifth decade, with equal frequen- anchors the stomach in place within the
radiation, which was associated with cies between the sexes and across all abdominal cavity, is a common cause.
nausea and emesis. Emesis was non- races. Acute gastric volvuli carry a Lengthening of the ligaments due to
bilious and non-bloody. The pain and mortality rate of 42–56%, secondary stretching gives rise to abnormal rotation
emesis were temporally concurrent. to gastric ischaemia, perforation or of the mesentery. In 30% of gastric
On review of systems, she denied any necrosis.1 volvuli, there is a primary cause.6
diaphoresis, shortness of breath, con- Classically, Borchardt’s triad of Secondary gastric volvuli have alternative
stipation, diarrhoea, previous similar vomiting, epigastric pain and an inabil- causes, including congenital or traumatic
episodes, and use of non-steroidal ity to pass an NGT should trigger one to diaphragmatic hernias, hiatal hernias,
anti-inflammatory drugs and alcohol. think of gastric volvulus as the primary eventration of the diaphragm, abdominal
Surgical history included laparoscopic diagnosis. Borchardt’s triad has been bands or adhesions.7 A retrospective
cholecystectomy. reported to occur in 70% of cases.2 analysis in 2004 found that seven out of
On physical examination, she was However, a retrospective study on the eight patients with the diagnosis of
found to be afebrile, with stable vital common presentations of chronic gas- gastric volvulus at the Kasturba
signs. She was in mild distress, spitting tric volvulus over a 5-year period has Medical College Hospital, Manipal,
into a wash basin. Abdominal exam-
ination revealed mild epigastric tender-
ness with normal active bowel sounds.
No peritoneal signs were noted.
Electrocardiography revealed a nor-
mal sinus rhythm, and a chest x ray
examination showed a large hiatal
hernia (fig 1). Laboratory testing
revealed only a mildly elevated white
cell count of 13.46109/l.
While in the emergency department,
she received antiemetic medications
with minimal relief. Use of a nasogas-
tric tube (NGT) alleviated some of the
symptoms; however, she continues to
have persistent nausea. The NGT suc-
tioned out 200 ml of clear, non-bilious
fluid. Her vital signs remained stable
and within normal limits during her
stay in the emergency room.
At that time, a small bowel follow-
through barium study was ordered,
which revealed a large gastric volvulus.
She was taken to the operating room
for surgical repair of the volvulus and
the hiatal hernia. A Nissen fundoplica-
tion and an anterior gastropexy were
performed. The patient recovered with-
out any complications, and was dis-
charged to a rehabilitation facility. Figure 1 Chest radiograph showing a large hiatal hernia.
www.emjonline.com
Emergency casebook 447
Figure 2 Organoaxial and mesenteroaxial rotation. Reproduced with permission from 2004 Learning Radiology.com
South India, between 1986 and 2000 considered carefully for conservative Emergency Medicine, 85 Seymour St, Hartford,
CT 06102, USA.
have a secondary cause, including even- treatment. The gold standard is open
tration of the diaphragm, Bockdalek laparotomy with detorsion and pre- Accepted 3 January 2007
hernia and incisional hernias.5 vention with anterior gastropexy.
Competing interests: None declared.
However, a study in 2000 with signifi- Nissen fundoplication decreases future
cantly more subjects found that the most occurrences in patients with a hiatal
common predisposing factor is a para- hernia.6 REFERENCES
oesophageal hiatal hernia (28/36).8 In summary, unless it stays in the
1 Green J. Gastric volvulus. Emedicine 2004.
Diagnosing a gastric volvulus is diffi- back of the diagnostician’s mind, gas- Available at http://
cult, since there is no one lab value/set of tric volvulus can be an easily missed www.imedicine.com.online.uchc.edu/
lab values sensitive enough to exclude diagnosis, which is associated with DisplayTopic.asp?bookid = 12&topic = 296.
2 Akoad M. Gastric volvulus. Emedicine, 2002.
the diagnosis. The gold standard is a significant morbidity and mortality. As http://www.imedicine.com.online.uchc.edu/
barium swallow, which has a very high mentioned above, patients do not DisplayTopic.asp?bookid = 6&topic = 2714
sensitivity and specificity for diagnosing always exhibit unstable vital signs and (accessed 16 March 2007).
a gastric volvulus. A recent study 3 Cozart JC, Clouse RE. Gastric volvulus as a cause of
distressed appearance. The presence of intermittent dysphagia. Dig Dis Sci
showed that a barium swallow is diag- a hiatal hernia with persistent vomiting 1998;43:1057–60.
nostic in 14 out of 25 cases and despite initial antiemetic treatment 4 http://www.LearningRadiology.com
suggestive in an additional 7 out of 25 5 Willsher PC, White RC, Dumbrell P. Idiopathic
should trigger one to think of gastric chronic gastric volvulus. Aust NZ J Surg
cases.7 However, there are case reports volvulus. With the advent of CT and 1996;66:647–9.
that advocate the use of abdominal CT, laparoscopic surgery, the gold stan- 6 Machado NO, Rao BA. Gastric volvulus
since it can give information about the with identifiable cause in adults. Presentation
dards for diagnosing and treating this and management. Saudi Medl J
position and anatomy necessary to disease are ever evolving. 2004;25:2032–4.
hasten surgical intervention.9 7 Kohli A, Vij A, Azad T. Intrathoracic gastric
Emerg Med J 2007;24:446–447.
Additionally, CTs can be performed in volvulus-acute and chronic presentation. J Indian
doi: 10.1136/emj.2006.041947 Med Assoc 1997;95:522–3.
a non-responsive patient who presents 8 Teague WJ, Ackroyd R, Watson DI, et al.
in a stable but critical status.9 10 ....................... Changing patterns in the management of
Treatment can be either surgical or gastric volvulus over 14 years. Br J Surg
Authors’ affiliations 2000;87:358–61.
medical in nature. Conservative man- Bang Chau, Susan Dufel, University of 9 Coulier B, Ramboux A. Acute obstructive
agement consists of endoscopic reduc- Connecticut Health Center, Emergency Medicine gastric volvulus diagnosed by helical CT.
tion or percutaneous endoscopic Residency, Hartford, Connecticut, USA Jbr-Brt Organe Soc R Belge Radiol
gastrostomy. The risk of gastric perfora- 2002;85:43.
10 Cherukupalli C, Khaneja S, Bankulia P, et al. CT
tion is significant in conservative treat- Correspondence to: Dr B Chau, Hartford diagnosis of acute gastric volvulus. Dig Surg
ment. Therefore, patients should be Hospital, UCONN Integrated Residency in 2003;20:497–9.
www.emjonline.com

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446 Emergency casebook

shown that dysphagia, epigastric pain

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