Emergency endoscopic reduction of a gastric volvulus

High risk and low incidence diseases: Pediatric digestive volvulus

INTRODUCTION

Pediatric digestive volvulus is a serious condition that carries with it a high rate of morbidity and mortality.

OBJECTIVE

This review highlights the pearls and pitfalls of pediatric digestive volvulus, including the presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Pediatric digestive volvulus is a deadly condition most commonly associated with malrotation. It occurs when the stomach or small intestine twists on itself, resulting in ischemia and potentially strangulation with necrosis and perforation. Presentation differs based on the gastrointestinal (GI) segment affected, degree of twisting, and acuity of the volvulus. Gastric volvulus most commonly presents with retching with or without nonbilious emesis and epigastric distension with pain, while midgut volvulus typically presents with bilious emesis in infants. Patients with GI necrosis and perforation may present with hemodynamic compromise and peritonitis. If suspected, emergent consultation with the pediatric surgery specialist is necessary, and if this is not available, transfer to a center with a pediatric surgeon is recommended. Imaging includes plain radiography, ultrasound, or upper GI series, while treatment includes resuscitation, administration of antibiotics, and emergent surgical decompression and detorsion of the involved segments.

CONCLUSION

An understanding of pediatric digestive volvulus and its many potential mimics can assist emergency clinicians in diagnosing and managing this deadly disease.

Acute Mesentero-Axial Gastric Volvulus in the Setting of a Paraesophageal Hernia: A Rare Case Report

Acute gastric volvulus is a surgical emergency that requires urgent intervention to prevent gastric ischemia and necrosis. Gastric volvulus manifests as an abnormal rotation or torsion of the stomach and may be associated with gastric outlet obstruction. This pathology can be classified as either mesentero-axial or organo-axial volvulus, depending on the axis of rotation. Similarly, it can be categorized as primary or secondary, depending on the etiology. We describe a case of a 63-year-old female with a history of peptic ulcer disease who presented with severe epigastric pain and vomiting of one-day duration. She was diagnosed with an acute mesentero-axial gastric volvulus, which was successfully reduced using a nasogastric tube.

A Twist in Crohn's Disease: A Rare Case of Gastric Volvulus

An 80-year-old male with a past medical history of Crohn's disease presented to the emergency department with complaints of nausea and multiple episodes of coffee-ground emesis and was initially diagnosed with upper gastrointestinal bleed. On physical examination, the patient was noted to have a mildly tense and tender abdomen with hyperactive bowel sound. His CT abdomen showed a markedly distended stomach with mesenteroaxial (MA) rotation and localized fluid in the left upper quadrant with the caudal displacement of the spleen due to the left upward position of the stomach. The gastric outflow tract was pinched to the left of the midline superior to the esophagogastric junction, consistent with the gastric volvulus. Endoscopic detorsion was initially planned, but it was unsuccessful due to the twisting of the distal stomach in the antrum. The patient underwent laparoscopic detorsion and gastropexy. He was found to be asymptomatic after the procedure and was discharged with outpatient follow-up. Gastric volvulus is a rare yet potentially fatal condition due to its variable presentation, and it can have lethal consequences if not treated properly and in a timely manner.

Emergent Repair of Paraesophageal Hernias and the Argument for Elective Repair

Background and Objectives:

A feared complication of large paraesophageal hernias is incarceration necessitating emergent repair. According to previous studies, patients who require an emergent operation are subject to increased morbidity compared with patients undergoing elective operations. In this study, we detail patients who underwent hernia repair emergently and compare their outcomes with elective patients.

Methods:

A retrospective analysis was performed of the paraesophageal hernia repair operations between 2010 and 2016. Patients were divided into 2 groups: patients with hernias that were repaired electively and patients with hernias that were repaired emergently. Perioperative complications and follow-up data regarding morbidity, mortality, and recurrence were also recorded. A propensity analysis was used to compare emergent and elective groups.

Results:

Thirty patients had hernias repaired emergently, and 199 patients underwent elective procedures. Patients undergoing emergent repair were more likely to have a type IV hernia, have a partial gastrectomy or gastrostomy tube insertion as part of their procedure, have a postoperative complication, and have a longer hospital stay. However, propensity analysis was used to demonstrate that when characteristics of the emergent and elective groups were matched, differences in these factors were no longer significant. Having an emergent operation did not increase a patient's risk for recurrence.

Conclusion:

Patients who had their hernias repaired emergently experienced complications at similar rates as those of elective patients with advanced age or comorbid conditions as demonstrated by the propensity analysis. The authors therefore recommend evaluation of all paraesophageal hernias for elective repair, especially in younger patients who are otherwise good operative candidates.

A rare cause of severe epigastric pain, emesis and increased lipase

INTRODUCTION

Gastric volvulus is an uncommon, but severe pathology requiring early diagnosis and urgent treatment. Its atypical symptoms and rarity make it difficult to diagnose, possibly leading to delayed treatment and fatal complications.

PATIENTS AND METHODS

We present a case of a 73-year-old patient with Parkinson's disease with complaints of severe epigastric pain, emesis and an increased lipase.

RESULTS

Diagnosis of an organo-axial gastric volvulus was made. Treatment consisted of reduction of the volvulus by decompression via nasogastric tube. The underlying cause was a para-esophageal hernia that was repaired by Nissen-fundoplication later on.

CONCLUSIONS

We describe symptomatology, diagnostic and therapeutic options of gastric volvulus.

Second-look laparostomy for perforated gangrenous gastric volvulus to prevent total gastrectomy

A 42-year-old Caucasian woman presented to the emergency department with severe upper abdominal pain and vomiting. Clinically, she was septic, and abdominal examination suggested peritonitis. Following immediate resuscitation, the patient was stabilised and underwent urgent contrast-enhanced CT of the abdomen and pelvis. This revealed a mesenteroaxial gastric volvulus with traction on the mesentery and a small volume of free fluid. She underwent laparotomy revealing gangrenous gastric fundus perforation complicated by persistent intraoperative hypotension. This mandated a damage-control approach for the patient's safety entailing a limited-sleeve gastrectomy and laparostomy formation. Stabilisation in the intensive care unit allowed for a safer return to the operating room. On second look 24 hours later, previously ischaemic non-viable-looking portions of the stomach had recovered their blood supply. The patient was discharged 31 days postoperatively after recovering from the operations, postoperative wound infections and pleural effusions.

Acute gastric volvulus: a deadly but commonly forgotten complication of hiatal hernia

Gastric volvulus is a rare condition resulting from rotation of the stomach beyond 180 degrees. It is a difficult condition to diagnose, mostly because it is rarely considered. Furthermore, the imaging findings are often subtle resulting in many cases being diagnosed at the time of surgery or, as in our case, at autopsy. We present the case of a 76-year-old man with an extensive medical history, including coronary artery disease with multiple bypass grafts, who became diaphoretic and nauseated while eating. His presumptive diagnosis at arrival to the hospital was an acute coronary event; however, his initial cardiac work-up was negative. A computed tomography scan revealed a type III hiatal hernia. The following day, after consistent complaints of nausea and episodes of nonbloody emesis, he suddenly became hypotensive, tachycardic and had an episode of coffee-ground emesis. Subsequently, the patient's condition suddenly deteriorated and resuscitation attempts were unsuccessful. The autopsy revealed a partially sliding hiatal hernia, which was consistent with the radiologic impression. Additionally, a gastric volvulus was present with extensive, focally transmural necrosis involving the body/fundus. Gastric volvulus is a rare entity with variable, nonspecific clinical presentations, which requires a high level of suspicion for radiologic diagnosis. Acute cases have a high mortality rate and require emergency surgery. This case highlights the value of autopsy in the diagnosis of unsuspected cases of gastric volvulus when death occurs prior to surgical intervention.

[Laparoscopic gastric sleeve in gastric volvulus secondary to diaphragmatic eventration in an adult patient]

BACKGROUND

Acute gastric volvulus is a rare, but potentially life-threatening, cause of upper gastrointestinal obstruction.

CLINICAL CASE

Male of 60 years old with severe epigastric pain and abdominal distension with haematemesis on two occasions. The patient was haemodynamically stable, with abdominal distension and palpable epigastric fullness. Hematic cytology showed: haemoglobin 8.2g/dl and haematocrit 27%. Abdominal X-ray showed an elevation of left diaphragm with a hugely dilated stomach. A nasogastric tube was inserted. Endoscopy was performed. There was no active bleeding, but it was impossible to reach the duodenum due to the stomach distortion. The upper gastrointestinal X-ray study showed the appearance of an inverted stomach in the chest and an organoaxial gastric torsion. The CT scans of thorax and abdomen showed a gastric ascent into the thoracic cavity. Laparoscopic surgery was performed, finding the left hemi-diaphragm elevated, and the stomach, splenic angle of the colon, the spleen and tail of the pancreas were also raised. A linear gastrectomy (gastric sleeve) was performed. The postoperative progress was satisfactory. Oral feeding was started 72 hours after surgery, and the patient was discharged, and has remained asymptomatic during the following by 8 years.

CONCLUSIONS

Emergency physicians must maintain a high level of suspicion in patients that present with signs and symptoms suggesting upper digestive tract occlusion. The gastric sleeve is an excellent alternative to avoid recurrence of gastric volvulus.

Paraoesophageal hernia: an overview

Paraoesophageal hernias are a rare but clinically important type of hiatus hernia. Gastric volvulus and perforation may ensue. Investigation and management is determined by patient presentation. This review summarizes current research regarding paraoesophageal hernias.

Miscellaneous disorders and their management in gastric surgery: volvulus, carcinoid, lymphoma, gastric varices, and gastric outlet obstruction

This article focuses on less common diseases that surgeons are called on for management options. Five topics-volvulus, carcinoid, lymphoma, gastric varices, and gastric outlet obstruction from peptic ulcer disease-are frequently used to evaluate surgical knowledge. Knowledge of these topics is useful for residents preparing for an in-training examination or board certification. Patients with these diseases require multidisciplinary management with oncologists and/or gastroenterologists, and mastery of these topics allows surgeons to effectively participate in the multidisciplinary care of these patients and advocate for surgical management when appropriate.