Lethal Acute Gastric Volvulus Masquerading in the Medical Unit Is Managable With a Laparoscopic Approach

Michael L Hibbard, MD, Giovanni Begossi, MD, Paul Suding, MD, Teresa Kim, MD, Greg Broderick-villa, MD, Rupert Horoupian, MD, Steven Stanten, MD, Ajay Upadhyay, MD. First Surgical Consultants, Alta Bates Summit Medical Center, Oakland, California, U.S.A and St. Rose Hospital, Hayward, California, U.S.A.

Purpose: Acute gastric volvulus associated with a large paraesophageal hernia is an uncommon entity but can be potentially serious and life threatening. The widely quoted classic diagnostic triad of Borchardt: (1) inability to vomit with retching; (2) upper abdominal distension; (3) inability to pass a tube into the stomach, may not be the presenting symptoms in all cases. Dramatic variations of atypical presentations (chest pain, shortness of breath, gastrointestinal bleeding) mimicking a medical condition have been described. This can lead to diagnostic delay and deleterious delay in surgical intervention. We describe the clinical presentation of patients with acute gastric volvulus associated with a large paraesophageal hernia presenting to a medical unit (medical floor, medical intensive care unit or coronary care unit) that subsequently required emergent surgical intervention.
Methods: Review of our series of elderly patients initially admitted to a medical unit with atypical symptoms who subsequently required emergent surgery for acute gastric volvulus in a large paraesophageal hernia between 2002 and 2011. Laparoscopic derotation of the stomach with cruroplasty was performed. Fundoplication and/or anterior gastrorrhaphy were used in select cases.
Results: Nine elderly patients (three females and six males) were initially admitted to a medical unit. Five patients (56%) had presented with chest pain as the predominant symptom. Four (44%) patients presented with gastrointestinal bleed. Abdominal discomfort or pain was a presenting symptom noted on the emergency room admission notes in four (44%) patients but was not considered significant by the admitting physician. Aspiration pneumonia was the admitting diagnosis in two (22%) patients. Sepsis with hypotension was present in three (33%) patients. An acute coronary event was suspected and ruled out in four (44%) patients prior to surgical consultation. A laparoscopic approach was used for derotation of the stomach, followed by cruroplasty in seven (78%) cases. One patient with morbid obesity and ischemic stomach underwent a laparoscopic vertical sleeve gastrectomy. One patient in septic shock with a pre-operative diagnosis of gastric perforation underwent an open approach, and a gastrectomy was performed. She subsequently expired on the 30th post operative day from multiple organ failure. This was the only mortality in our series.
Conclusions: A variety of unusual case presentations of acute gastric volvulus leading to delay in the diagnosis have been reported. Though patients presenting with atypical symptoms must be ruled out for life-threatening cardiopulmonary diseases, in the setting of a large paraesophageal hernia, acute gastric volvulus must be considered in the differential diagnosis. The medical practitioner must keep an especially high index of suspicion for acute gastric volvulus in the setting a negative cardiac work-up in order for a timely diagnosis and prompt surgical consultation. Despite the predominantly advanced ages and multiple co-morbidities seen in our patients, a laparoscopic approach was feasible.

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