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

Abstract

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.

Keywords: Autopsy; Hernia, Hiatal; Stomach Volvulus.

Figure 1. Unenhanced abdominal CT from a prior study demonstrating a large type III hiatal hernia, with the majority of the stomach located within the thoracic cavity. A - Axial plane. B - Coronal plane. A = gastric antrum; F = gastric fundus; G = gastric body; H = heart; L = liver; arrowheads = gastric greater curvature; white arrows = diaphragmatic hiatus; * = gastroesophageal junction.

Figure 2. Autopsy photos. A - Enlarged and tortuous stomach with focal full-thickness wall discoloration (arrow); B - Significant portion of stomach above the left hemi-diaphragm.

Figure 3. Gross appearance of the stomach. A - Extensive gastric mucosal necrosis of gastric body/fundus with ulcerations; B - Formalin-fixed stomach with a sharp line of demarcation showing the sparing of the antral/pyloric mucosa.

Figure 4. A - Gross finding of the trachea with coffee-ground material within the lumen; B - Gross photo of the lung with coffee-ground material within the distal bronchial tree (probe).

Figure 5. Photomicrography of the lung showing food particles within bronchi and alveoli (H&E, 20X).

Figure 6. Gross finding of the heart showing an intact, clean bypass graft from the aorta to the circumflex coronary artery branch.

Figure 7. Contrast-enhanced CT of the abdomen performed on admission. A - Coronal images demonstrate the upward rotation of the stomach along its long axis, which is new compared to the prior study, resulting in inversion of the gastric greater curvature (GC) above the lesser curvature (LC) consistent with organoaxial gastric volvulus. Marked gastric distension and retention/reflux of debris into the superior portion of the intrathoracic esophagus (E) reflect obstruction at the level of the diaphragmatic hiatus. A portion of the gastric fundus (F) has herniated back into the abdominal cavity, which is also likely contributing to obstruction. B - Axial images also demonstrating organoaxial gastric volvulus. The marked gastric distension with abrupt transition to normal caliber at the gastric antrum (A), which is compressed as it passes through the diaphragmatic hiatus, indicates this as the level of obstruction. B = gastric body; F = gastric fundus/body; H = heart; * = gastroesophageal junction.