Prof. Dr. Fawzy Megahed Khalil Commentary case By Prof. Dr. Fawzy Megahed Khalil Ass. Lec. Rafaat Saied 8-3-2017

A 61-year-old white woman with chest pain for months before presented to the Emergency Department with complainting of progressively worsening localized, burning, left-sided and substernal chest pain that was identical to her previous myocardial infarction.

Chest pain was associated with nausea, vomiting, and shortness of breath. She experienced no relief with the administration of sublingual nitroglycerin and aspirin

Due to her prior history of coronary artery disease with left anterior descending artery stent placement, acute coronary syndrome was highest on her differential diagnosis list during her visits to the hospital

she underwent a nuclear medicine stress test, followed by a left heart catheterization 2 weeks prior to this hospitalization in another state during an acute episode of chest pain.

During that hospitalization, the stress test showed no evidence of inducible myocardial ischemia and the left heart catheterization showed only mild to moderate stenosis of the left anterior descending artery with a patent stent.

No history of hematemesis prior to her admission, prior history of gastrointestinal bleed, or use of high-risk medications such as nonsteroidal anti-inflammatory drugs.

Her past medical history was significant for coronary artery disease with left anterior descending artery stent placement, chronic kidney disease stage 3, hiatal hernia with gastroesophageal reflux disease, and depression

Surgical history consisted of her prior angioplasty, a vaginal hysterectomy, and tonsillectomy.

Family history of breast cancer in her maternal grandmother and paternal grandfather and was a life-long nonsmoker who consumed alcohol only on special occasions.

Vital signs were entirely within normal limits and she appeared to be resting comfortably with no evidence of distress. Apart from vague epigastric tenderness, she exhibited no abnormalities on physical examination.

complete blood count was within normal limits and comprehensive metabolic profile was unremarkable apart from her creatinine of 1.38 mg/dL, which was near her baseline.

She had a lipase of 59 U/L. Her D-dimer and troponin I were both unremarkable, with electrocardiogram showing normal sinus rhythm without evidence of ischemia. She experienced an episode of emesis at this time that was brown and tested positive for occult blood. Subsequent stool for occult blood was negative.

She underwent overnight cardiac monitoring with serial cardiac biomarker testing, was made nil per os, and was started on intravenous fluid hydration and intravenous proton pump inhibitor therapy.

CHEST X RAY WAS DONE

Her chest radiograph

Her chest radiograph showed a large hiatal hernia, an epigastric air-fluid level (Figures 1 and 2), and no evidence of acute cardiopulmonary disease

DIAGNOSIS

Gastroenterology was consulted for concerns of upper gastrointestinal bleeding.

EGD that showed a large paraesophageal hernia and gastric volvulus.

Imaging via upper gastrointestinal series with small bowel follow-through that showed the stomach in an organoaxial position without evidence of gastric volvulus and with normal transit of contrast into the small bowel

The intermittent nature of her gastric volvulus was confirmed via its presence on EGD examination and absence on the upper gastrointestinal series.

General Surgery was then consulted and performed reduction of the hiatal hernia followed by a Nissen fundoplication.

Intraoperatively, she was noted to have approximately 80% of the stomach herniated through the hiatal defect.

She tolerated the procedures well and was started on a liquid diet She tolerated the procedures well and was started on a liquid diet. Within a day, she tolerated a full diet, with no further complaints of chest pain or refluxand was discharged home in stable and improved condition.

This case posed a diagnostic dilemma as a result of the patient’s prior cardiac history, presence of symptoms identical to her previous myocardial infarction, the intermittent nature of her volvulus, and lack of anemia or previous gastrointestinal bleed.

Volvulus can lead to mucosal ischemia, resulting in necrosis, shock, and possibly death if not detected and intervened upon in a timely manner.

Gastric volvulus Gastric volvulus is a rare condition with peak incidence after approximately age 50 years, with adults comprising > 80% of cases.

Gastric volvulus occurs when the stomach rotates upon its horizontal or vertical axis, compromising blood flow and potentially leading to gastric outlet obstruction.

Gastric volvulus may present as organoaxial, mesenteroaxial, or combined varieties. Approximately 60% of gastric volvulus cases encountered are of the organoaxial variety and are associated with diaphragmatic hernias, paraesophageal hernias, and diaphragmatic eventration

Gastric volvulus is diagnosed based upon a combination of history and imaging findings. Classically, a spherical bubble with large air- fluid level in the epigastric or retrocardiac region is present on chest or abdominal radiograph

Additionally, computed tomography imaging may be of use, as it would demonstrate the positioning of the displaced stomach as well as any anatomic abnormalities that may predispose to the volvulus

Electrolyte abnormalities may be present as a result of emesis, decreased oral intake, and dehydration. If gastrointestinal bleeding is an accompanying symptom, anemia may additionally be present

Initial treatment consists of stabilization with fluid resuscitation and correction of electrolytes Nasogastric decompression should be attempted to relieve symptoms and may result in spontaneous de-torsion of the stomach

Endoscopic intervention may prove to be beneficial in such cases Endoscopic intervention may prove to be beneficial in such cases. Decompression of the stomach provides symptom relief in addition to decreasing the risk of ischemia and further complications.

The definitive treatment includes surgical restoration of normal anatomic position of the stomach with repair of any hernial defects

Several surgical procedures have been described, but the most commonly performed procedure is open reduction with or without gastropexy.

In high-surgicall risk patients, a conservative approach such as endoscopic de-rotation and placement of percutaneous gastrostomy tube, or laparoscopic surgery, can be attempted

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