PICTURES IN DIGESTIVE PATHOLOGY

 

Paraesophageal hernia and gastric volvulus: an uncommon etiology of vomiting and upper gastrointestinal bleeding

 

 

Gonçalo Nunes¹, Marta Patita¹, Vítor Fernandes¹ and Jorge Fonseca^1,2

¹Gastroenterology Department. Hospital Garcia de Orta. Almada, Portugal.
²CiiEM - Centro de Investigação Interdisciplinar Egas Moniz. Monte da Caparica, Portugal

 

 

Case report

A 75-year-old woman was admitted to the Emergency Room with abdominal pain and coffee ground vomiting persisting for three days and presented marked epigastric distension and tenderness. Laboratory analysis revealed dehydration with kidney injury (creatinine 2.8 mg/dl), hypokalaemia (K+ 2.6 mmol/l) and hypernatremia (Na+ 148 mmol/l). Endoscopy showed a black esophagus covered with dark fluid, hyperaemia and erosions (Fig. 1), a large paraesophageal hernia and marked distortion of gastric anatomy caused by stomach rotation (Fig. 2). Nine liters of gastric fluid were aspirated and the pylorus was not identified. X-ray and CT scan confirmed the presence of an organoaxial gastric volvulus with antero-superior rotation and incarceration of the gastric antrum, located above the diaphragm (Fig. 3). Emergency surgery repaired the diaphragmatic hernia, achieved volvulus reduction and a Nissen fundoplication was performed to prevent recurrence. The patient was discharged without any complications.

 

 

 

 

Discussion

Gastric volvulus is an uncommon entity defined by abnormal rotation of the stomach of more than 180 ^oC, creating a closed-loop obstruction that may result in incarceration and organ necrosis. Three types of volvulus are classically described: organoaxial, mesenteroaxial and the very rare combined type (1). The organoaxial subtype accounts for 59% of patients and usually coexists with diaphragmatic defects and hiatal hernia (1). Vomiting often occurs due to gastric outlet obstruction and bleeding results from mucosal ischemia and sloughing. Emergency surgery is required to resolve the volvulus and prevent complications as without surgical intervention, an acute organoaxial volvulus has an 80% mortality rate (2). With a modern surgical approach, mortality is reduced to 15-20% (2,3).

 

References

1. Ferrer-Márquez M, García-Díez JM, Parra-Montoya F, et al. Gastric volvulus associated with cardiac tamponade. Rev Esp Enferm Dig 2011;103(9):498-500. DOI: 10.4321/S1130-01082011000900015.         [ Links ]

2. Palanivelu C, Rangarajan M, Shetty AR, et al. Laparoscopic suture gastropexy for gastric volvulus: A report of 14 cases. Surg Endosc 2007;21(6):863-6. DOI: 10.1007/s00464-006-9089-4.         [ Links ]

3. Katkhouda N, Mavor E, Achanta K, et al. Laparoscopic repair of chronic intrathoracic gastric volvulus. Surgery 2000;128(5):784-90. DOI: 10.1067/msy.2000.108658.         [ Links ]