An 81 year old woman presented to our department with a two day history of nausea and retching but was unable to vomit..

Picture Quiz

Nausea with a twist

Kenneth J Porter, Daniel Thomas, Rajab Kerwat, Sumantra Kumar

Correspondence to: K J Porter kenjporter@hotmail.com

[EXCERPTS]

An 81 year old woman presented to our department with a two day history of nausea and retching but was unable to vomit. For the past three weeks she had been experiencing dysphagia with only small amounts of liquid tolerated, excessive belching, and weight loss. She had no abdominal pain and her bowels were opening normally. She had a known hiatus hernia and previous oesophagitis for which she was taking regular omeprazole.

On examination she did not have a fever but she was dehydrated and tachycardic. Her abdomen was soft and non-tender and a cardiorespiratory examination showed no abnormalities. She underwent chest radiography and computed tomography of her chest and abdomen.

 

Questions

1 What are the differential diagnoses for this patient?

2 What is the abnormality on computed tomography?

3 What is the most likely diagnosis?

4 How can this condition be treated?

Answers

1 What are the differential diagnoses for this patient?

Short answer

The differential diagnoses include proximal upper gastrointestinal obstruction secondary to oesophageal motility disorders, reflux oesophagitis, peptic ulcer disease, oesophageal or gastric cancer, and complicated hiatus hernia.

2 What is the abnormality on computed tomography?

Short answer

The cross sectional (fig 3) and coronal computed tomography (fig 4) images show a large air-containing organ in the posterior mediastinum that has two chambers separated by a septum.

The differential diagnoses include proximal upper gastrointestinal obstruction secondary to oesophageal motility disorders, reflux oesophagitis, peptic ulcer disease, oesophageal or gastric cancer, and complicated hiatus hernia.

2 What is the abnormality on computed tomography?

Short answer

The cross sectional (fig 3) and coronal computed tomography (fig 4) images show a large air-containing organ in the posterior mediastinum that has two chambers separated by a septum.

3 What is the most likely diagnosis?

Short answer

A gastric volvulus.

Fig 5Schematic drawing of stomach, its ligamental attachments, and types of gastric volvulus. Left: organo-axial volvulus; right: mesentero-axial volvulus. Reproduced, with permission, from Elsevier

The presentation of a gastric volvulus is varied and correlates with the speed of onset. Acutely, patients may develop severe epigastric pain and retching without vomiting. These symptoms and the inability to pass a nasogastric tube represent a triad of findings that is diagnostic of acute gastric volvulus and reportedly occurs in 70% of cases. Patients with more chronic presentations may have non-specific symptoms such as dysphagia and bloating. These symptoms can often be missed or attributed to other conditions such as peptic ulcer disease.

The diagnosis of gastric volvulus can be confirmed by the following radiological modalities:

  • Chest radiography. This may show an air filled sac behind the heart shadow described as a precardiac air bubble or a fluid filled sac.
  • Plain abdominal radiography. This may show a massively distended viscus in the upper abdomen. In a mesentero-axial volvulus findings include a spherical stomach on supine images and two air fluid levels on erect images, with the antrum positioned superior to the fundus.
  • Upper gastrointestinal contrast studies. These are sensitive and specific if performed when the stomach is in the €œtwisted € state and may show an upside down stomach.
  • Computed tomography. This shows the whole anatomy of the stomach, making precise diagnosis possible. Specific advantages include the ability to detect the presence or absence of gastric pneumatosis and free air, and the exclusion of other abdominal pathology.

4 How can this condition be treated?

Short answer

It should initially be treated conservatively with fluids and electrolyte correction, but the mainstay of treatment is decompression, reduction, and prevention of recurrence, which can be accomplished with surgery in the form of a laparoscopic reduction with excision of the hernial sac, hiatal defect repair, and gastropexy.

Patient outcome

The patient underwent a laparoscopic reduction of her mesentero-axial gastric volvulus. The hernial sac was excised, the hiatal defect was repaired, and a gastropexy was performed. She needed support in an intensive care unit after surgery and another gastroscopy to correct some bleeding from a duodenal ulcer. She then made an unremarkable recovery and was discharged home two weeks later.

[Link to free BMJ article for full text with long answers, images, and references]

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