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Gastric volvulus involving the duodenum
  1. Alejandro Gabriel Plana1,
  2. Thomas G Cotter2 and
  3. Kiran K Turaga3
  1. 1 Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
  2. 2 Department of Gastroenterology, University of Chicago Hospital, Chicago, Illinois, USA
  3. 3 Department of Surgery, University of Chicago Hospital, Chicago, Illinois, USA
  1. Correspondence to Dr Kiran K Turaga, kturaga{at}uchicago.edu

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Description

A 55-year-old woman presented with a 2-day history of abdominal pain, multiple episodes of non-bloody, non-bilious emesis and inability to tolerate oral intake. Her medical history included recurrent small bowel obstructions status-post multiple exploratory laparotomies and decompressive gastrostomy tubes with recent functional gastropexy, and recurrent superior mesenteric venous thrombosis status-post stent placement (figure 1, red arrow).

Figure 1

(A) Transverse abdominal CT. Orange arrow indicates proximal point of the volvulus. Red arrow indicates the previously stented superior mesenteric vein. (B) Composite image taken from CT with contrast (highlighted as red–orange in the image). Proximal end of the volvulus and pyloric sphincter (blue arrow) shown, with partial visualisation of red–orange contrast in the duodenum (brighter red in the image. (C) X-ray image taking during oesophagogastroduodenoscopy (OGD), showing a large segment of the endoscope traversing the stomach. Middle portion of OGD scope correlates with the proximal duodenum.

Physical examination revealed epigastric tenderness without peritoneal signs or distention. Labs included a normal white cell count, haematocrit, serum lipase and lactate. Abdominal CT with oral contrast revealed massive dilation of the stomach (figure 1A, orange–red contrast). Oesophagogastroduodenoscopy under fluoroscopy (figure 1B) revealed a functional volvulus involving the distal stomach and proximal duodenum that was easily traversable without interventional manoeuvre despite abnormal orientation on X-ray (figure 1C).

This case illustrates a rare manifestation of gastric volvulus, which classically presents as either organoaxial or mesenteroaxial rotation with no involvement of the duodenum.1 In this case, the axes of rotation were the distal stomach (figure 1A, orange arrow) and the proximal duodenum. Exploratory laparotomy resulted in successful volvulus reduction with tacking of the stomach wall to the anterior abdominal wall at multiple sites. While the common symptom of abdominal pain was present, none of the anatomic abnormalities commonly seen in gastric volvulus case were noted: agenesis, elongation or disruption of the gastric ligaments (primary volvulus); or para-oesophageal hernia, diaphragmatic hernia or phrenic nerve paralysis (secondary volvulus).2

Learning points

  • Not all gastric volvulus cases present with the pathognomonic Borchardt’s Triad— retching without vomiting, epigastric pain and inability to pass a nasogastric tube—particularly cases with more distal obstruction, which can present with vomiting.

  • Should initial endoscopic reduction fail for gastric volvulus, surgery with reduction and gastropexy should be considered, while gastrostomy tube placement can be trialled in poor surgical candidates.

References

Footnotes

  • Contributors AGP crafted the text, synthesised the clinical details and submitted the manuscript. KKT edited and provided substantial feedback and context for the patient’s care. TGC similarly edited the case report and provided substantial feedback on the text.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Obtained.

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