Hussam Kaka, PGY-2 August 2017 Gastric Volvulus Hussam Kaka, PGY-2 August 2017

Case A 94-year-old man presented to the emergency department with 5 days of intermittent vomiting Initially white vomitus which turned black on the second day Last bowel movements 5 days ago Vital signs are stable and afebrile Lactate 8.7

Case Radiograph taken in the ER Showed large hiatal hernia with a second “gastric bubble” under the left hemidiaphragm Concern was raised for gastric volvulus

Gastric Volvulus A rare clinical entity defined as abnormal rotation of the stomach > 180⁰ Life-threatening entity Three types Organo-axial: most common Rotation along an axis joining the gastroesophageal junction and the pylorus Mesentro-axial: Rotation along an axis perpendicular to its longitudinal axis Combined organo-axial and mesentro-axial: rarest subtype

Gastric volvulus: types

Gastric volvulus: clinical presentation 10-20% occur in children < 1 year old The majority of cases occur in adults in the fifth decade Causes foregut obstruction which can be acute, intermittent, recurrent or chronic Borchardt triad was described in the literature Severe sudden epigastric pain Intractable wretching without vomiting Inability to pass an NG tube Mortality of 30-50% makes early diagnosis key

Back to case: representative CT images CT confirms the presence of a large hiatal hernia

Back to case: representative CT images Note the pylorus lies above the GE junction: mesentro-axial volvulus

Back to case: representative CT images Note the greater curvature lies medial to the lesser curvature: organo-axial volvulus

Back to case: representative CT images Kinked NG is consistent with the known difficulty of insertion in cases of gastric volvulus

Case summary Combined mesentro-axial and organo-axial volvulus Life threatening emergency which can lead to gastric strangulation In accordance with the patient’s wishes, a nonsurgical palliative approach was pursued and the patient passed away within 48 hours