P2080 - Gastric Volvulus: An Underrated Complication of Hiatal Hernia

Shehroz Aslam, MD¹, Mustafa Alani, MD², Zaid Ansari, MD³, Jacob Moussa, MD¹, Indu Srinivasan, MD⁴, Keng-Yu Chuang, MD^3
1Creighton University, Dignity Health St. Joseph's Medical Center, Phoenix, AZ; ²Creighton University School of Medicine, Phoenix, AZ; ³Creighton University School of Medicine Phoenix Program, Phoenix, AZ; ⁴Creighton University/Valleywise Health, Phoenix, AZ

Introduction: Gastric volvulus is a rare clinical condition defined as an abnormal rotation of the stomach along its short or long axis; mesenteroaxial or organoaxial rotation respectively. It was first described in 1866 as an autopsy finding. It can lead to gastric outlet obstruction, and in severe cases strangulation, necrosis, and perforation. Here, we are presenting an interesting case of gastric volvulus diagnosed with imaging and endoscopy subsequently treated surgically.

Case Description/Methods: A 55 years old Caucasian male presented with severe epigastric abdominal pain, retching, and vomiting for three weeks. The patient had a past medical history of untreated large hiatal hernia that was diagnosed seven years ago. Vital signs were stable, physical examination revealed mild epigastric tenderness with no peritonitis or localizing signs. Abdominal images showed a large-sized hiatal hernia with signs of mesenteroaxial gastric volvulus (Figure 1). After fluid resuscitation, nasogastric (NG) tube placement was unsuccessful on multiple attempts. Endoscopy showed large hiatal hernia, erythematous and twisted mucosa in the mid gastric body (Figure 1). An attempt to reduce the volvulus endoscopically was unsuccessful. Given these findings and concern for early vascular compromise with gastric incarceration, the patient was taken to the operation room for robotic-assisted laparoscopic hiatal hernia repair and reduction of the stomach. The intraoperative findings confirmed type IV hiatal hernia with antrum, pylorus and duodenum incarcerated into thoracic cavity causing gastric outlet obstruction. Postoperatively patient had an uneventful recovery, he was able to tolerate oral intake and discharged home on postoperative day three.

Discussion: Gastric volvulus is a rare condition that can be life-threatening if the diagnosis is delayed. Acute gastric volvulus symptoms include pain in the upper abdomen or lower chest associated with unproductive retching and inability to pass a NG tube, known as Borchardt's triad. Despite established literature on diagnosis and treatment, many cases of gastric volvulus are underdiagnosed adding to its associated morbidity and mortality (ranging up to 50% in acute cases). Although endoscopic management has been reported in selected cases, gastric volvulus is usually managed surgically to prevent serious complications like gangrene and perforation.


Figure: Figure 1: Radiographic and endoscopic images of gastric volvulus, a: pylorus, b: duodenal bulb, c: fundus


Disclosures:
Shehroz Aslam indicated no relevant financial relationships.
Mustafa Alani indicated no relevant financial relationships.
Zaid Ansari indicated no relevant financial relationships.
Jacob Moussa indicated no relevant financial relationships.
Indu Srinivasan indicated no relevant financial relationships.
Keng-Yu Chuang indicated no relevant financial relationships.


Shehroz Aslam, MD¹, Mustafa Alani, MD², Zaid Ansari, MD³, Jacob Moussa, MD¹, Indu Srinivasan, MD⁴, Keng-Yu Chuang, MD³. P2080 - Gastric Volvulus: An Underrated Complication of Hiatal Hernia, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.