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Q1: What do the chest radiographs show?
The chest radiographs appear to show a hiatus hernia with a fluid level (fig 1, arrowed) but no free gas under the diaphragm or intramural air.
Q2: What single diagnostic investigation is required?
An urgent gastroscopy should be performed.
Passage of the endoscope through the oesophagus was achieved without difficulty. Upon entering the proximal stomach, the mucosa appeared normal; the lumen was not readily visualised and a large acute gastric volvulus with a paraoesophageal hernia was diagnosed. The endoscope was carefully manipulated through the narrowed lumen formed by the twisted gastric folds of the fundus and advanced into the distal body and antrum. The volvulus was decompressed aspirating 1.2 litres of bloodstained fluid and then subsequently reduced with the gastroscope. Thereafter, within 15 hours the patient's symptoms cleared and his renal function was back to normal by which time he no longer required further resuscitation from intravenous fluids.
He later went on to have an elective fundoplication of the paraoesophageal hernia; this prevents further recurrence of the gastric volvulus.
Acute gastric volvulus is unusual, with over 300 cases being reported since the initial description by Berti in 1866.1It is seen in all ages with a peak incidence in the fifth decade. The mortality rates are high mainly from gastric infarction, varying from 30% to 50%.2 Unfortunately this often reflects the delay in diagnosis and treatment particularly when gastric volvulus is not considered.
The classic Borchardt's triad of nausea, vomiting, severe constant chest or epigastric pain, and difficulty in passing a nasogastric tube should raise the suspicion of acute gastric volvulus3particularly when there is an associated paraoesophageal hernia. The acute form is seen less often than the chronic (almost half of cases). Seemingly vague symptoms of nausea and vomiting may be one of the presenting complaints and can surprisingly be over- looked, so making the diagnosis difficult. Our case shows this point well, where the volvulus was camouflaged by renal impairment presumed initially to be secondary to lithium toxicity. An erect chest radiograph should give clues to the diagnosis also, for example, the presence of double air fluid levels—beneath the left hemidiaphragm and in the retrocardiac mediastinum as described by Rosselet.4
Gastric volvulus presents acutely with closed loop obstruction (which contributed towards this patient's renal impairment), strangulation, ischaemia, or perforation of gastric viscus. These patients have rotations greater than 180 degrees in the cardiopyloric or mesenteroaxial plane. Vascular compromise leads to gastric gangrene in 5% to 28% of patients presenting with acute gastric volvulus.5
Nausea and vomiting should always be taken seriously.
Borchardt's triad of constant epigastric pain, nausea/vomiting and difficulty in passing a nasogastric tube should suggest the presence of acute gastric volvulus.
Chest radiograph usually shows the presence of paraoesophageal hernia with two air fluid levels: one beneath the left hemidiaphragm and the other in the retrocardiac mediastinum.
Gastroscopy is useful in the initial diagnosis and the treatment but surgery still remains the definitive treatment.
The definitive treatment of patients with gastric volvulus has been surgical to reduce the volvulus, thereby correcting the underlying pathological feature.6 If gastric necrosis is found, the stomach is repaired by local excision, subtotal or even total gastrectomy. Anterior gastropexy in which the greater curve of the stomach is fixed to the undersurface of the anterior abdominal wall is performed to prevent recurrence.
Non-surgical correction of acute gastric volvulus is also of benefit as it allows time for elective surgical repair so as to avoid gastric ischaemia. This includes nasogastric decompression or endoscopic reduction. The latter technique involves the formation of a loop in the form of an alpha, further advancement of the endoscope tip into the antrum of the stomach, and uncoiling of the “alpha loop” with subsequent reduction of the gastric volvulus.7
Acute gastric volvulus must therefore be considered early in the differential diagnosis of nausea and vomiting, especially after a normal clinical examination.
We believe this is under-recognised at initial presentation because the symptoms are not taken seriously and perhaps a little underestimated.
Acute gastric volvulus with paraoesophageal hernia.