Acute Gastric Volvulus Causing Splenic Avulsion and Hemoperitoneum

Abstract

Gastric volvulus is an abnormal, potentially life-threatening, torsion of the stomach. The presence of complications such as hemoperitoneum increases the diagnostic urgency; however it can also mask the presentation of gastric volvulus. We encountered a 66-year-old female who presented with symptomatic gastric outlet obstruction and was found to have hemoperitoneum and splenic avulsion on imaging. In our case, hemoperitoneum was a clinical red herring as initial imaging concentrated on the presence of hemoperitoneum and was nondiagnostic of gastric volvulus. Interestingly, our patient experienced complete resolution of her presenting symptomatology following placement of a nasogastric tube. Furthermore, endoscopic evaluation revealed no overt pathology to explain outlet obstruction. In light of these findings, gastric torsion was strongly suspected. A repeat CT scan was confirmatory, elucidated reduction of the stomach to its anatomic position, retroactively diagnosing a gastric volvulus. This case is unusual in its presentation and setting. The patient presented with two rare complications of gastric volvulus, hemoperitoneum and splenic avulsion. Additionally, ten years prior to this presentation the patient had a temporary gastrostomy tube. Gastropexy with a gastrostomy is the treatment for gastric volvulus and should have been preventative of her presentation with torsion. Furthermore, the gastric volvulus was not initially recognized radiographically due to the presence of masking radiographic findings. This case serves to highlight the utility of clinical acumen and maintain a high index of suspicion for gastric volvulus in all cases presenting with Borchardt's triad.

‘Back-and-Forth Stomach’ CT Imaging Findings of a Pathophysiologic Entity Causing Acute Gastric Volvulus

“…Regarding the presenting symptoms, these depend on the rapidity of onset, degree of gastric rotation, amount of obstruction and final position of the stomach [1,8,12,[32][33][34]. Our series is in agreement with previous studies [9,35], with epigastric or lower thoracic abdominal pain associated with vomiting being the most frequent clinical presentation and common in all cases. Borchardt's triad, which includes the inability to pass the NGT, was found in three cases (42.9%), a significantly lower percentage than that described in classic series (70%) [7].…”

“…Endoscopic decompression and gastrostomy, described in elderly [1] and high-surgical-risk [38] patients as a conservative method of management, was not performed in any of our patients. Of note, these conservative strategies are not without risk since there is a significant risk of perforation [7], and cases of GV have even been reported in patients with gastrostomy [9,39]. All the approaches were performed by laparotomy, although the use of laparoscopy has been described in the literature since 2004 [40] in high-risk elderly patients [37,38], and successful outcomes have been reported using endoscopic techniques [41].…”

“…Since then, numerous case reports and series have been published, contributing to a better understanding of GV. Although sociodemographic data are limited [6], no significant differences in its incidence have been described in terms of sex or race, and it is more frequent in the fifth decade of life [2,[7][8][9]. Because the clinical presentation of GV is nonspecific, imaging examinations are required for appropriate diagnosis.…”

Acute Mesentero-Axial Gastric Volvulus in the Setting of a Paraesophageal Hernia: A Rare Case Report

“…4 The last subtype is a combination or unclassified volvulus. 3,4 Seventy-percent of acute gastric volvulus cases demonstrate Borchardt's triad of epigastric pain, retching with emesis, and the inability to pass a nasogastric tube. 1,3,6,[8][9][10][11][12][13][14] Other symptoms include radiation of the epigastric pain to the back, neck or chest, dysphagia, vomiting, and abdominal distention.…”

“…3,4 Seventy-percent of acute gastric volvulus cases demonstrate Borchardt's triad of epigastric pain, retching with emesis, and the inability to pass a nasogastric tube. 1,3,6,[8][9][10][11][12][13][14] Other symptoms include radiation of the epigastric pain to the back, neck or chest, dysphagia, vomiting, and abdominal distention. 5,6 Complications include strangulation leading to ischemia, necrosis, and gangrene along with the risk of perforation, ulceration, and hemorrhage.…”