Acute gastric volvulus with pneumatosis intestinalis and portal venous gas secondary to hiatus hernia induced gastric outlet obstruction

Abstract

An 80-year-old female presented to emergency department with persistent nausea, vomiting, upper abdominal pain and generalized malaise. She had a similar presentation for a large para-oesophageal hiatus hernia 2 weeks prior which was managed conservatively with nasogastric decompression and a planned gastroscopy. Her relevant past medical history included hypertension and gastro-oesophageal reflux disease. Her vital signs were stable with resting tachycardia (105 beats per minute). She was clinically dehydrated. A large dilated stomach with positive succussion splash was appreciated on palpation. Her abdominal examination was otherwise benign with no peritonism. Initial blood investigations showed an elevated white cell count (19.2 × 10/L) with neutrophilia (17.5 × 10/L) and elevated serum lactate of 3.7 mmol/L. She had evidence of acute kidney injury and hypochloraemic metabolic alkalosis secondary to dehydration from chronic vomiting (creatinine 140 μmol/L; chloride 89 mmol/L; base excess 13.1 mmol/L). Computed tomography (CT) of the abdomen demonstrated a large complex hiatus hernia which was unchanged from the previous CT scan performed 2 weeks ago. There were new findings of gastric mural pneumatosis (Fig. 1a) and porto-venous gas (Fig. 1b). The appearances were suggestive of mesenteroaxial gastric volvulus. Her clinical symptoms settled with gastric decompression and appropriate intravenous volume replacement. She was maintained nil-per-oral and transferred to the nearest tertiary hospital under the specialist surgical team for appropriate intervention within 24 h. Gastroscopy was performed on the same day, which revealed a large hiatus hernia and multiple erosions without signs of acute volvulus. In the absence of gastric necrosis and acute volvulus, the patient underwent laparoscopic reduction of hiatus hernia with anterior fundoplication and cruroplasty 2 days later. Intraoperatively, the stomach was noted to be viable. The patient made a remarkable progress and was discharged on the fourth post-operative day. Gastric volvulus represents an abnormal rotation of the stomach of more than 180 around its axis. It can cause strangulation of the stomach with a mortality rate of 30–50%; however, it is relatively rare due to its rich vascular supply from the coeliac trunk and its branches. There are primary (idiopathic) and secondary forms of gastric volvulus. Secondary causes include para-oesophageal hernia, left diaphragmatic eventration, pyloric stenosis and intra-abdominal adhesions. Radiologically, it can be classified based on its axis of rotation. Organo-axial volvulus, being the most common variant, is usually associated with hiatal hernia and is characterized by rotation around pyloro-cardia axis. The greater curvature of the stomach lies superior to the lesser curvature. In contrast, mesenteroaxial volvulus is identified by twisting of the stomach along lesser curvature axis leading to rotation of antrum and pylorus superior to the gastrooesophageal junction. Although not present in our patient, Borchardt’s triad, which consists of epigastric pain, unproductive retching and inability to pass an nasogastric tube, is prevalent in the majority of acute gastric volvulus cases. A CT scan should be sought early to define the anatomy,