Acute Intrathoracic Gastric Volvulus due to Diaphragmatic Hernia: A Rare Emergency Easily Overlooked

Abstract

Acute intrathoracic gastric volvulus occurs when the stomach undergoes organoaxial torsion in the chest due to either concomitant enlargement of the hiatus or a diaphragmatic hernia. Iatrogenic diaphragmatic hernia can occur after hiatal hernia repair and other surgical procedures, such as nephrectomy, esophagogastrectomy and splenopancreatectomy. We describe a 49-year-old woman who presented to our emergency department with acute moderate epigastric soreness and vomiting. She had undergone extensive gynecologic surgery including splenectomy 1 year before. The chest radiograph obtained in the emergency department demonstrated an elevated gastric air-fluid level in the left lower lung field. An urgent gastroscopy showed twisted structural abnormality of the stomach body. A computed tomography scan demonstrated the distended stomach, located in the left lower hemithorax through a left diaphragmatic defect. Emergent transthoracic repair was performed. Postoperative recovery was uneventful, and the patient did not experience any pain or difficulty with eating.

Keywords: Diaphragmatic hernia; Emergency; Gastric volvulus; Torsion.

Fig. 1

Chest radiographic findings. Chest radiograph at admission demonstrates a high gastric air-fluid level on the left lower lung field (arrow) and elevated gastric contour (dotted line). The silhouette of heart and bony thorax shows no abnormal findings, and neither does the mediastinum.

Fig. 2

Gastroscopic examination. a Gastroscopy demonstrates a large greenish fluid collection with a few food materials at the greater curvature side of the mid body of the stomach just after passing the esophagogastric junction (white arrow). There are no mucosal abnormalities such as hyperemia, fresh blood or old blood clots. b Retroflex view by gastroscopy revealed extreme twisting of the stomach (white arrow). The torsion of the stomach twisted the fundus and changed the anatomical structure so much that the fluid collection is not observed in the fundus, noticed in an ordinary situation (blue arrows).

Fig. 3

CT findings. A chest CT scan demonstrates the butterfly-like gastric wall silhouette (dotted line) in the left lower hemithorax. One part of the stomach is filled with fluid (yellow arrow) and the other part with air (blue arrow). The twisted point is observed also (white arrow).