Acute gastric volvulus: a deadly but commonly forgotten complication of hiatal hernia

Abstract

Gastric volvulus is a rare condition resulting from rotation of the stomach beyond 180 degrees. It is a difficult condition to diagnose, mostly because it is rarely considered. Furthermore, the imaging findings are often subtle resulting in many cases being diagnosed at the time of surgery or, as in our case, at autopsy. We present the case of a 76-year-old man with an extensive medical history, including coronary artery disease with multiple bypass grafts, who became diaphoretic and nauseated while eating. His presumptive diagnosis at arrival to the hospital was an acute coronary event; however, his initial cardiac work-up was negative. A computed tomography scan revealed a type III hiatal hernia. The following day, after consistent complaints of nausea and episodes of nonbloody emesis, he suddenly became hypotensive, tachycardic and had an episode of coffee-ground emesis. Subsequently, the patient's condition suddenly deteriorated and resuscitation attempts were unsuccessful. The autopsy revealed a partially sliding hiatal hernia, which was consistent with the radiologic impression. Additionally, a gastric volvulus was present with extensive, focally transmural necrosis involving the body/fundus. Gastric volvulus is a rare entity with variable, nonspecific clinical presentations, which requires a high level of suspicion for radiologic diagnosis. Acute cases have a high mortality rate and require emergency surgery. This case highlights the value of autopsy in the diagnosis of unsuspected cases of gastric volvulus when death occurs prior to surgical intervention.

An Overview of Gastroduodenal Perforation

“…Although the stomach has a good blood supply, on occasions severe foregut ischemia can lead to gastric ischemia and perforation, although such patients are generally unwell before the perforation is manifest (22). If perforation is in the thorax as in the case of strangulated hiatus hernia (HH), then the patient is likely to have chest symptoms and general signs of severe sepsis, with little or no evidence of peritonitis (21).…”

“…Perforated hiatus hernia or gastric volvulus, when part or all of the stomach is in the chest, present extremely difficult scenarios. Surgery in this situation may require thoracotomy, resection, and then a decision made regarding primary or delayed reconstruction (21,22). The influencing factors are the time since presentation, degree of mediastinal and pleural soiling, and the general condition of the patient (21,22,95).…”

“…It is important to note that in this era of effective treatment of PUD with H. pylori eradication and proton pump inhibitors (PPIs), gastric cancer is commonly a cause of gastric outlet obstruction and perforation as opposed to peptic ulcer disease ( 20 ). Gastric volvulus and strangulated hiatus hernia ( 21 ) can lead to perforation if all or part of the stomach wall is rendered ischemic. Although the stomach has a good blood supply, on occasions severe foregut ischemia can lead to gastric ischemia and perforation, although such patients are generally unwell before the perforation is manifest ( 22 ).…”

Gastric Volvulus: A Complication of Hiatal Hernia

“…Type 3 is a combination form of organoaxial and mesenteroaxial rotation, accounting for only 2% of cases. Type 4 is unclassified (occurs in 10% of cases) [6].…”

Acute Gastric Volvulus With Perforation

“…Классические клинические проявления во взрослом периоде описываются триадой Борхардта (70%): боли в эпигастрии, многократная рвота, невозможность проведения желудочного зонда. У взрослых па-циентов нередко заболевание протекает под ма-ской острого коронарного синдрома, обусловли-вая высокий процент диагностических ошибок, нередко заканчиваясь летально [6]. С целью до-полнительного обследования показано выполне-ние рентгенографии органов брюшной полости с обязательным захватом грудной клетки, где, как правило, визуализируется один или два больших уровня жидкости в проекции желудка, при вторич-ном завороте -с внутригрудным расположением желудка [7].…”