Gastric organoaxial volvulus: A lethal twist and a rare cause of acute abdomen

Abstract

Organoaxial gastric volvulus is a rare clinical condition. We present a 55 years old man with an acute episode of melena and hematemesis with moderate epigastric pain which was unresponsive to analgesics. Initially, the patient was misdiagnosed and treated symptomatically for other gastrointestinal conditions but later contrast-enhanced abdominal CT scan revealed gastric organo-axial volvulus, which was associated with a right hiatal hernia. The patient underwent surgical treatment, including crural dissection, posterior esophageal window creation, lower esophageal sling, crural defect repair with porcine meshes, and anterior gastropexy, followed by intensive physiotherapy and antibiotics. Diagnosis of gastric volvulus can be challenging, due to its symptom similarity to other gastrointestinal disorders, necessitating a high level of suspicion.

Introduction

Gastric volvulus is a rare clinical event [1]. The first case of gastric volvulus was described by Berti in 1866 as an autopsy finding of a woman who died after a severe obstructive acute abdomen [2]. Gastric volvulus is defined as an abnormal rotation of all or parts of the stomach upon itself at 180° or more. It can be classified depending on the axis of rotation, organo-axial or mesentero-axial, or a combination of both; and its chronicity, acute versus chronic [3]. The organoaxial rotation of the stomach is the most common gastric volvulus (two-thirds of cases) and occurs when the stomach rotates around the pylorus and the gastroesophageal (GE) junction [4]. The presentation of gastric volvulus can be acute or chronic. In approximately 70% of acute organoaxial volvulus cases, patients typically present with Borchardt's triad; sudden onset of intense epigastric pain, retching with no emesis, and failure to advance a nasogastric tube [5]. Acute gastric volvulus patients may also present with gastric strangulation leading to necrosis, perforation, and eventually sepsis [4]. Other complications include necrosis of the pancreas [6] and avulsion of omentum [7]. The mortality rate of gastric volvulus is about 42%-56% [5]. The gold standard approach to detect a gastric volvulus is barium swallow [1].

We report a case of gastric organoaxial volvulus in a patient who presented with gastrointestinal (GI) bleeding, abdominal discomfort, and epigastric pain, who had been initially misdiagnosed for other GI conditions and treated symptomatically. Our case report not only adds to the rarity of this condition in medical literature but also fortifies the imaging modality for its accurate diagnosis.

Case presentation

A 55 years old man was presented in the emergency department with an acute episode of melena and hematemesis associated with moderate epigastric pain for 1 day which was unresponsive to analgesics. The pain was sudden-onset, progressively worsening with moderate intensity in the epigastric region that radiated to the right hypochondrium. He experienced a similar episode 1 day before, which was managed symptomatically; however, it did not completely resolve. History revealed caustic soda ingestion 24 years ago followed by surgical repair and occasional dysphagia to solids after that. He remained almost symptom-free until 2 years back when he developed a similar episode of hematemesis and melena which was treated symptomatically. He had no history of chronic use of NSAIDs, tobacco, or alcohol.

Upon physical examination, the patient exhibited epigastric and right hypochondriac tenderness. Laboratory investigations for Hepatitis B (HBV) and Hepatitis C (HCV) yielded unremarkable results. Additionally, serum markers including alanine aminotransferase (ALT), aspartate aminotransferase (AST), and gamma-glutamyl transferase (GGT) were also normal. Blood profile showed hemoglobin of 3.3 g/dL and low hematocrit which were immediately managed by blood transfusions and IV fluids. The patient had no signs of portal hypertension, cirrhosis, or hepatitis, and neither the patient had any history of peptic ulcer disease. The etiology remained unclear until radiological investigations. A contrast-enhanced abdominal CT scan was performed to investigate the source of the bleeding. Findings shown by the contrast-enhanced abdominal CT scan of the patient are shown and described in Figs. 1 and 2.

Fig. 1.

Nonenhanced computed tomography (NECT) abdomen, coronal section, soft tissue window showing fundus and body of stomach rotated and displaced within right thoracic cavity (marked by red arrow).

Fig. 2.

CECT Chest at the level of the base of heart, axial section, soft tissue window showing herniation of pylorus into right lung base with the widening of intercrural distance (marked by blue arrow). The wall of herniated stomach is thickened and edematous (marked by a white arrow).

These findings revealed that the stomach had herniated into the right thoracic cavity through the right hiatal hernia, consistent with a diagnosis of gastric organoaxial volvulus and a right hiatal hernia.

The patient had an emergent surgery to correct the volvulus. After surgery, the patient was closely monitored in the surgical high-dependency unit and then transferred to the surgical ward after 24 hours. He received intensive physiotherapy and antibiotics, which resulted in steady improvement. Ten days postsurgery, the patient was discharged from the hospital. The patient has since undergone follow-up after 9 months and has remained asymptomatic.

Discussion

Intrathoracic gastric volvulus is a rare condition that can be easily overlooked when evaluating causes of dysphagia, vomiting, epigastric pain, heartburn, and upper abdominal reflux, as it resembles other gastrointestinal diseases like gastritis or gastroesophageal reflux disease [8]. Diagnosing it promptly can be difficult, which makes it important to keep in mind. Medical literature shows that it is a rare finding when gastric volvulus is associated with a right-sided sliding diaphragmatic hernia, which causes the stomach to dislocate (whole or in part) into the right thoracic cavity [9], consistent with our patient's finding.

Volvulus can be classified as primary or secondary. Primary etiology includes laxity of stomach-anchoring ligaments [1]. Secondary etiologies consist of diaphragmatic defects including hernias or eventration, or intra-abdominal defects such as adhesions or bands [10]. The clinical picture of gastric volvulus is described as Borchardt's triad, which includes severe sudden epigastric pain, intractable retching without vomiting, and inability to pass a nasogastric tube. Intrathoracic gastric volvulus may also be associated with strangulation or obstruction of the stomach, further complicating the condition [9]. This is a fatal condition and is considered a surgical emergency because if it is not timely diagnosed and managed promptly, severe complications may arise which may lead to death of the patient. Out of the severe complications, one is upper GI bleeding, which results from gastric mucosal sloughing, resulting in compromised blood flow [11]. Our patient presented with the same complication of acute gastric volvulus and was misdiagnosed until he presented again in an emergency with the same complaints. As a result of profound blood loss, his Hb dropped to 3.3 mg/dL which required immediate resuscitation by blood and fluid infusions. The diagnosis remained unclear until abdominal CT with contrast demonstrated stomach rotation associated with the right hiatal hernia through which the stomach was herniated into the right hemithorax.

Our patient's presentation, when coupled with the delay in diagnosis and management, emphasizes the importance of having a high level of clinical suspicion for gastric volvulus, which is often overlooked, being a rare condition. Upper GI bleeding is a suggestive sign of abnormalities in various body structures, including up to the suspensory ligament of the duodenum. This can present as melena and/or hematemesis. A thorough patient history can help rule out many etiologies, narrowing them down to a few possibilities. While suspicion may point towards esophageal varices due to portal hypertension or hemorrhage from peptic ulcer disease but our patient's negative history for peptic ulcer disease and absence of jaundice, hepatomegaly, splenomegaly, or portal hypertension during examination indicated a different etiology.

There are 3 subtypes of gastric volvulus including organoaxial, mesenteroaxial, and mixed. In organoaxial, a CT scan shows inverted stomach has a horizontal lie, greater curvature lies superior to the lesser curvature. In mesenteroaxial, a CT scan shows the stomach has a vertical lie, the anthropologic junction is displaced above the gastroesophageal junction. In mixed subtypes, a CT scan shows the combination of findings for organoaxial and mesentero-axial subtypes.

Treatment of gastric volvulus in adults can involve surgical or nonsurgical interventions, depending on the presentation, which can be approached through the thoracic or abdominal route [3]. With the advent of laparoscopic approaches, surgeries have become less invasive. Percutaneous endoscopic gastrostomy combined with endoscopic de-rotation is effective and safe in patients with isolated gastric volvulus [12,13]. A laparoscopic gastropexy is also a well-described approach for treating both acute as well as chronic gastric volvulus [[14], [15], [16]–17].

Conclusion

In conclusion, gastric volvulus is a rare clinical entity that can lead to serious complications. The diagnosis of gastric volvulus can be challenging, as its symptoms can mimic those of other gastrointestinal conditions, and a high degree of suspicion is required. An early diagnosis and prompt surgical intervention are crucial in preventing serious complications and reducing mortality rates associated with gastric volvulus.

Ethical approval

Not required as we have acquired consent from the patient.

Author contribution

All authors contributed equally.

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Patient consent

Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.