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

2. 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

3. 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

4. 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

5. Gastric volvulus: types

6. 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

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

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

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

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

11. 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