Acute gastric volvulus: a rare but real surgical emergency

Acute gastric volvulus is a rare disease that requires a high index of suspicion for diagnosis and rapid treatment. Many cases occur with a paraesophageal hernia or diaphragmatic eventration. It is potentially life threatening because delayed diagnosis and treatment may result in perforation, infarction, and other lethal results. The signs and symptoms of acute gastric volvulus include abdominal pain and distention, especially in the upper abdomen, and vomiting with progression to nonproductive retching. Because of the rarity of this disease, common gastrointestinal complaints may mislead the emergency department (ED) physician to diagnose a nonsurgical gastrointestinal disease if a detailed history and physical examination are not obtained. Traditionally, it is diagnosed by seeing intrathoracic viscera in the chest radiograph, followed by a barium contrast study or upper gastrointestinal endoscopy. Currently, computed tomography allows an immediate diagnosis with all the anatomical details. The whirl sign, which is an important characteristic of gastrointestinal volvulus, is rarely seen on computed tomography in gastric volvulus. Acute gastric volvulus is regarded as a surgical emergency, requiring either open or laparoscopic surgery. We report a case of acute gastric volvulus secondary to a paraesophageal hernia that presented with acute abdominal pain and fullness and had an unfavorable outcome. This should remind all ED physicians to maintain a high index of suspicion for this disease when treating patients with acute abdominal pain and to seek immediate surgical intervention once diagnosed. Acute gastric volvulus is a rare disease that requires a high index of suspicion for diagnosis and rapid treatment. The signs and symptoms of gastric volvulus depend on the rapidity of onset and degree of rotation and obstruction. It is potentially life threatening because delayed diagnosis and treatment may lead to perforation, infarction, and other lethal results. We report a case of acute gastric volvulus secondary to a paraesophageal hernia that presented with acute abdominal pain and fullness and had an unfavorable postoperative outcome. A 70-year-old man presented to our emergency department (ED) with a 1-day history of acute abdominal distention with severe epigastralgia and nausea. He had long been affected by intermittent irritable chest and abdominal discomfort. A paraesophageal hernia had been diagnosed based on computer tomography (CT) 5 years earlier. At that time, elective surgical intervention was refused because of the reversibility of his symptoms. He denied a history of hypertension, diabetes, cardiovascular diseases, or any systemic illness. On arrival in the ED, the physical examination revealed diffuse tenderness and equivocal rebound pain over the epigastric area. The bowel sounds were hyperactive. The initial electrocardiograph was unremarkable. He had a blood pressure of 95/75 mm Hg, a heart rate of 130 beats per minute, a respiratory rate of 17 times per minute, and a body temperature of 36.9°C. The laboratory results were as follows: white blood count 17 600/μL with 87.5% segmented neutrophils, blood urea nitrogen 26 mg/dL, creatinine 2.20 mg/dL, amylase 196 U/L, lipase 147 U/L, and C-reactive protein 35.45 mg/L. The other results were unremarkable. A nasogastric tube was inserted without difficulty, and more than 2 L of coffee-ground content was drained within 4 hours. The chest radiograph showed a huge bubble in the right lung field (Fig. 1). Contrast-enhanced dynamic CT of the chest and abdomen showed the whirl sign, with a severely distended stomach located in both the chest and abdominal cavity (Figs. 2 and 3). With a working diagnosis of acute gastric volvulus with severe obstruction, surgical intervention was advised. However, the patient still refused surgery and requested conservative treatment. Unfortunately, the patient became dyspneic and hypotensive 10 hours later. Resuscitation and an emergency laparotomy were performed immediately and a huge hiatal hernia with gastric volvulus and incarceration was identified. The fundus of the stomach was located in the peritoneal cavity and was markedly cyanotic, with gangrenous change and perforation. A total gastrectomy with an end jejunostomy and transthoracic repair of the diaphragmatic hernia with a transcervical esophagectomy and cervical esophagotomy were done. The patient was admitted to the intensive care unit postoperatively and was transferred to an ordinary ward 1 week later. He was discharged 3 weeks later with a temporary feeding jejunostomy. Gastric volvulus is defined as rotation of the stomach or part of the stomach by more than 180°, creating a closed-loop obstruction [1]. Mostly, it happens in the fifth decade of life [2]. It can be classified by anatomy, etiology, or the axis of rotation. The most common type in adults is the organoaxial type, which means that the stomach rotates along the longitudinal axis. Many cases occur with a paraesophageal hernia or diaphragmatic eventration [3]. Acute gastric volvulus can be catastrophic because of complications such as strangulation, infarction, perforation, or bleeding. The signs and symptoms of acute gastric volvulus include abdominal pain and distention, especially in the upper abdomen, and vomiting with progression to nonproductive retching. It is traditionally diagnosed by seeing intrathoracic viscera in the chest radiograph; this can be followed by a barium contrast study or upper gastrointestinal endoscopy. Currently, CT can lead to an immediate diagnosis with all the anatomical details [4]. On CT, a stomach in an unusually high position or with an abnormal axis in a patient with acute abdominal pain and vomiting should make one suspect gastric volvulus [5]. The whirl sign is an important characteristic of gastrointestinal volvulus, whereas it is rarely seen on CT in gastric volvulus [6]. An elevated amylase, as in our case, and alkaline phosphatase can mislead the ED physician [7,8]. Acute gastric volvulus is regarded as a surgical emergency, requiring either open or laparoscopic surgery [5,9], although a few cases, particularly of mesenteroaxial-type volvulus, can be resolved successfully on decompression with a nasogastric tube [1]. In our case, a paraesophageal hernia had been well documented 5 years earlier. The fundus was in the thoracic cavity on CT (Fig. 4). When the fundus rotated back into the abdominal cavity, it caused a close loop and acute volvulus of the stomach. As the patient had a symptomatic paraesophageal hernia, he should have undergone elective surgical repair to avoid catastrophic complications such as bleeding or volvulus [10]. Although rare, hematemesis with gastrointestinal bleeding may be the initial presentation or one of symptoms of acute gastric volvulus [5,11-13]. Because of the rarity of this disease, common gastrointestinal complaints may mislead the ED physician to diagnose a nonsurgical gastrointestinal disease if a detailed history and physical examination are not obtained. The delayed surgery was also responsible for the unfavorable outcome. Emergency department physicians should maintain a high index of suspicion for this disease when treating patients with acute abdominal pain and seek surgical intervention immediately once the diagnosis is made.