Air Care Series: Acute Gastric Volvulus

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HISTORY OF PRESENT ILLNESS:

The patient is a female in her 50s who presented to the emergency department via helicopter EMS altered with active hematemesis. The patient initially presented to a rural fire station with profuse hematemesis and a chief complaint of abdominal pain. In route the patient became altered and hypotensive leading the transport team to begin transfusing the patient. On arrival to the Shock Resuscitation Unit transfusion of packed red blood cells were ongoing.  

PHYSICAL EXAMINATION:

The patient was a cachectic, ill appearing female, with active hematemesis. The patient was tachycardic without other cardiac abnormalities. The abdomen was distended and diffusely tender. The patient spontaneously moved all four extremities but was altered and unable to follow commands. The patient was cool to the touch. The patient’s physical exam was otherwise  unremarkable. 

PAST MEDICAL HISTORY:

Alcoholic Cirrhosis

Hysterectomy

ALLERGIES:

Sulfa antibiotics

SOCIAL HISTORY:

Alcohol abuse

VITAL SIGNS:

BP 70/30

HR 120-130

Oxygen Saturation: 88% on NRB

LABS AND IMAGING:

WBC 10.9, Hb 14.1

Lactic Acid 3.8

INR 1.1

VBG: 7.36/53/+3.5

Sodium 141, Potassium 3.1, Cl 95, BUN 26, Cr 0.84, Bicarb 25, AG 21, Glucose 383

Total bilirubin 0.5, Direct bilirubin 0.1, AST 16, ALT 26, ALP 210, Albumin 2.1

FAST examination was adequate and negative. Portable chest x-ray showed low lung volumes with severely distended bowel loops in the upper abdomen which are incompletely visualized.

Portable abdominal x-ray: pneumoperitoneum

 HOSPITAL COURSE:

Upon arrival to the emergency department the patient was hypoxic, hypotensive, and tachycardic with active hematemesis. The patient was rapidly intubated and Minnesota tube placement was attempted, given hematemesis in a patient with a known history of alcohol abuse. Minnesota tube placement was ultimately unsuccessful as the tube could not be advanced beyond 20 centimeters. The patient was treated with intravenous pantoprazole, octreotide, ceftriaxone. The patient was transfused a second unit of pRBCs and FFP leading to improvement in her blood pressure. Acute Care Surgery was consulted following evidence of pneumoperitoneum on radiographic studies and patient was taken to the operating room for exploratory laparotomy. The exploratory laparotomy revealed evidence of a gastric volvulus and the patient underwent detorsion of the volvulus, lysis of adhesions, and partial gastrectomy with temporary closure. The following day, the patient returned to the operating room for G-tube and J-tube placement with EGD and closure of the abdomen. The patient was extubated on hospital day 2 and was discharged home to self-care on hospital day 10.

DISCUSSION:

Clinical Presentation and Epidemiology

Acute gastric volvulus is an emergent condition resulting from an abnormal rotation of the stomach causing obstruction, ischemia, and potential viscous perforation.1 The diagnosis of gastric volvulus requires a high level of suspicion from the provider. The classic presentation of acute gastric volvulus is based on Borchardt’s triad of severe abdominal pain, retching, and the inability to pass a nasogastric tube.2 The patient may begin with productive vomiting, but this will often transition to nonproductive retching. There may be blood in the productive emesis if present, which is typically related to mucosal ischemia. This triad has been reported in up to 70% of cases of acute gastric volvulus.3 Patients additionally often present with hematemesis either from mucosal tearing or mucosal sloughing in the setting of ischemia.4 Additionally, patients may also present with cardiovascular and respiratory compromise, often sequelae of gastric necrosis and perforation.

Gastric volvulus has a bimodal pattern of incidence, presenting in both pediatric and adult populations. Gastric volvulus presents at a mean age of 24 months within the pediatric population and is commonly associated with anatomic anomalies of the surrounding organs.5,6 In the adult population, acute gastric volvulus presents in the fifth decade of life with both sexes equally affected. Risk factors for gastric volvulus include abnormalities of the diaphragm (table 1) as well as history of surgery due to the presence of adhesions.1 The mortality of gastric volvulus is reported to be between 15% to 50%, making early diagnosis and intervention important factors in patient survival.1,4

Classification

Gastric volvulus can be classified based on the etiology of the rotation. The stomach is fixated within the abdomen by four ligaments: the gastrocolic ligament, the gastrohepatic ligament, the gastrophrenic ligament, and the gastrosplenic ligament. Primary gastric volvulus is due to abnormalities of these ligaments due to adhesions, neoplasia, or laxity of the gastric ligaments.4 Secondary gastric volvulus is due to abnormality of gastric or nearby organ anatomy, often associated with a paraesophageal hernia or traumatic diaphragmatic injury.1 Gastric volvulus is also classified by the axis of malrotation. Organo-axial volvulus occurs in the setting of rotation around the axis of the gastroesophageal junction and the pylorus. Typically, primary gastric volvulus is associated with an organoaxial torsion pattern while secondary volvulus tends to present with a mesenteroaxial pattern7. This results in an “upside down” appearance of the stomach with the greater curvature in a superior position relative to the lesser curvature of the stomach.4 Mesenteroaxial volvulus occurs due to rotation around the axis bisecting the greater and lesser curvature of the stomach1 (See figure 1).8

Diagnosis

As acute gastric volvulus can present with nonspecific findings of abdominal pain and retching, the differential diagnosis can be broad and include bleeding esophageal varices and gastric outlet obstruction. Pancreatitis as well as acute coronary syndrome may also be in the differential with upper abdominal pain/lower chest pain and retching. Physical examination can assist in narrowing the diagnostic possibilities. In patients with acute gastric volvulus, the clinician may appreciate upper abdominal fullness and distension in addition to the presence of gastric sounds in the chest on auscultation of the thorax. Failure of attempts to place either orogastric, nasogastric, or Minnesota tubes may also help in making the diagnosis. Radiographic assistance is frequently needed to aid in the diagnosis of gastric volvulus. Indications of this diagnosis on abdominal x-ray include the presence of two air fluid levels in the antrum and fundus of the stomach.1 If the clinical suspicion is high, but these signs are absent on plain radiographs, then CT imaging is indicated. In a study from in the British Journal of Surgery, barium contrasted studies make the diagnosis of gastric volvulus in 84% (21 out of 25) of patients.9 However, if the patient is in extremis and barium swallow cannot be performed, plain radiography of the chest and/or abdomen can be performed, understanding that it is less reliable diagnostically. Upper endoscopy is also of diagnostic value in acute gastric volvulus. The benefit of upper endoscopy as a diagnostic test in the setting of suspected gastric volvulus is that it offers both diagnostic and therapeutic potential. Diagnosis of gastric volvulus endoscopically allows for the possibility of endoscopic reduction and fixation with a percutaneous gastrostomy tube during the procedure.10

Management

The primary treatment for acute gastric volvulus is surgical intervention. Prior to surgical intervention, attempts to decompress the stomach with a nasogastric tube may be made, but are frequently unsuccessful. Conservative management with nasogastric decompression and monitoring may be an appropriate consideration in hemodynamically stable patients11. Patients who are in extremis and show signs of gastric perforation or significant gastrointestinal bleeding should not undergo conservative management.

The operative procedure used to treat the patient’s volvulus is guided by the unique underlying cause of each case, with open surgical reduction being the most common procedure performed. Surgical intervention not only includes removal of tissue with evidence of necrosis, but also involves repairing defects to prevent recurrence of the volvulus. Given the increased risk of open surgical procedures, laparoscopic and endoscopic options are an evolving option.4 A 2016 study by Light et al showed shorter length of hospitalization in patient’s undergoing laparoscopic repair of their gastric volvulus compared to patients undergoing an open approach. However, this same study also showed a higher rate of recurrence in patient’s undergoing endoscopic management.12

 Summary

Acute gastric volvulus occurs due to an abnormal rotation of the stomach given gastric ligament or other anatomic abnormalities within the abdomen. Patients typically present with abdominal pain and vomiting due to complications of obstruction, ischemia, or perforation. Plain radiography is the initial test of choice, although CT studies are frequently required. Most patients will require open surgical reduction and fixation; however, initial management should include decompression of the stomach with a nasogastric tube. Laparoscopic and endoscopic options have become more common due to the benefit of decreased length of hospitalization, especially in patients who are at high risk for complication from open operative intervention. 

AUTHORED BY Stephanie Winslow, MD (@StephaniEMDoc)

Dr. Winslow is a second -year Emergency Medicine resident at the University of Cincinnati.

FACULTY EDITORS Annals of B Pod Editors

References:

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