Intermittent Gastric Volvulus: Diagnostic Dilemma in a Patient with Recurrent Upper Abdominal Symptoms

Aims Gastric volvulus is a rare clinical entity characterized by the rotation of the stomach, which can lead to life-threatening complications. It may present acutely or chronically, with symptoms varying depending on the degree of obstruction and the rapidity of onset. Intermittent form often present with recurrent episodes of postprandial vomiting, epigastric pain, and bloating, which may resolve spontaneously but can progress to severe complications if not diagnosed and managed promptly.

This case report presents a 67-year-old woman with a medical history of hypertension, dyslipidemia, diabetes, and chronic NSAID use, who presented with chronic postprandial vomiting and epigastric pain suggestive of ulceration, evolving over two months with recent worsening [1].

Methods On examination, the patient was afebrile, with moderate dehydration, a BMI of 32 kg/m², and mild epigastric tenderness. Laboratory results revealed functional acute kidney injury, hypokalemia (3.01 mmol/L), and significant inflammation (CRP elevated from 27 to 180 mg/L over 48 hours, leukocytosis at 14,000/mm³). She had been treated symptomatically without improvement. A chest X-ray revealed a retrocardiac hydro-aeric image. Upper gastrointestinal endoscopy showed a large mixed hiatal hernia with a distended hernial pouch. After aspirating 1 liter of fluid, a spiral twist at the neck of the hernial sac was visualized, obstructing access to the pylorus, with no ischemic signs. The passage through the twist was challenging, causing friction. An irreducible loop formed within the pouch, preventing further advancement of the endoscope. Abdominal CT confirmed a rolling hiatal hernia containing both gastric and colonic segments, with a mesenteroaxial volvulus of the herniated part of the stomach. A functional pyloric stenosis was noted, causing upstream esogastric distension, primarily with liquid content. No pneumoperitoneum was observed.

Results The patient underwent surgical devolvulation, hernial sac resection to prevent recurrence, anti-reflux procedure,and gastropexy to secure the stomach in place.

Postoperatively, the patient developed severe diabetic ketoacidosis, requiring Intensive Care Unit admission, and subsequently acquired nosocomial pneumonia. Unfortunately, she succumbed to complications of acute respiratory distress syndrome.

Conclusions This case highlights the importance of considering intermittent gastric volvulus in the differential diagnosis of chronic vomiting in adults. While prompt diagnosis and surgical intervention are essential, postoperative complications, especially in patients with multiple comorbidities, can lead to significant morbidity and high mortality risk.

Publikationsverlauf

Artikel online veröffentlicht:
27. März 2025

• References

• 1 Costa M.A., da Silva S.D., Moreira A.C., Santos T., Noronha J., Moreira R.. Chronic gastric volvulus with diaphragmatic eventration: Case presentation. International Journal of Surgery Case Reports 2023; 106: 109095