Acute gastric volvulus: a deadly but commonly forgotten complication of hiatal hernia
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.
1. Guillén-Paredes MP, Pardo-García JL. Acute gastric volvulus: a case report. Rev Esp Enferm Dig. 2015;107(3):173-4.
2. Kim HH, Park SJ, Park MI, Moon W. Acute intrathoracic gastric volvulus due to diaphragmatic hernia: a rare emergency easily overlooked. Case Rep Gastroenterol. 2011;5(2):272-7. http://dx.doi.org/10.1159/000328444. PMid:21887128.
3. Wani BN, Jajoo S. Gastric volvulus. Indian J Surg. 2010;72(2):163-4. http://dx.doi.org/10.1007/s12262-010-0039-y. PMid:23133236.
4. Ajao OG. Gastric volvulus: a case report and a review of literature. J Natl Med Assoc. 1980;72(5):520-2. PMid:7381959.
5. Altintoprak F, Yalkin O, Dikicier E, et al. A rare etiology of acute abdominal syndrome in adults: gastric volvulus- Cases series. Int J Surg Case Rep. 2014;5(10):731-4. http://dx.doi.org/10.1016/j.ijscr.2014.08.024. PMid:25217876.
6. Kohn GP, Price RR, DeMeester SR, et al. Guidelines for the management of hiatal hernia. Surg Endosc. 2013;27(12):4409-28. http://dx.doi.org/10.1007/s00464-013-3173-3. PMid:24018762.
7. Kulkarni K, Nagler J. Emergency endoscopic reduction of a gastric volvulus. Endoscopy. 2007;39(Suppl 1):E173. http://dx.doi.org/10.1055/s-2007-966584. PMid:17614069.