Gastric Volvulus as a Complication of Giant Hiatal Hernia: A Case Report and Literature Review

Abstract

Gastric volvulus is a rare but potentially life-threatening condition that can arise as a complication of a giant hiatal hernia. It results from an abnormal rotation of the stomach, which can lead to obstruction, ischemia, or even gastric necrosis. Prompt recognition and surgical intervention are essential to prevent serious outcomes. We present the case of a 58-year-old female patient with a history of hypertension who arrived at the emergency department with acute-onset severe epigastric pain (10/10 on the Visual Analog Scale), accompanied by nausea but no vomiting. Physical examination revealed involuntary guarding in the epigastric region. Initial imaging with contrast-enhanced esophagogram showed a giant hiatal hernia with intrathoracic migration of the stomach and signs of gastric volvulus. A subsequent computed tomography (CT) scan confirmed the herniation of the gastric antrum through the esophageal hiatus with organoaxial rotation. The patient underwent urgent laparoscopic surgery. Intraoperatively, the stomach was found to be viable, with no evidence of necrosis or perforation. The herniated stomach was reduced, and the esophageal hiatus was dissected and repaired using a prosthetic mesh. The patient had an uneventful postoperative course and was discharged on the second postoperative day. She remains asymptomatic at follow-up. This case highlights the importance of early diagnosis and intervention in patients with acute gastric volvulus, especially when associated with a giant hiatal hernia. Laparoscopic repair remains the gold standard, offering reduced morbidity, faster recovery, and favorable long-term outcomes. A literature review confirms that surgical correction of the anatomical defect is essential to prevent recurrence and severe complications such as ischemia or gastric necrosis. Endoscopic and percutaneous decompression may serve as temporary measures but are not substitutes for definitive surgical treatment.

Keywords: esophagogram; gastric volvulus; giant hiatal hernia; laparoscopic surgery; organoaxial rotation.

Figure 1. Upper gastrointestinal contrast study showing a large intrathoracic stomach. A frontal radiograph with oral contrast demonstrates a markedly distended stomach herniated into the thoracic cavity (outlined by the red circle), consistent with a giant hiatal hernia. The red arrow indicates the transition point between the esophagus and the volvulized portion of the stomach, suggesting organoaxial gastric volvulus. Air-fluid levels and abnormal gastric positioning above the diaphragm are evident, supporting the diagnosis. This imaging finding correlates with the patient's acute epigastric pain and clinical signs of gastric obstruction.

Figure 2. Axial contrast-enhanced computed tomography image at the level of the lower thorax demonstrates a diaphragmatic defect at the esophageal hiatus (red arrow), with intrathoracic herniation of the gastric fundus and body. The stomach appears dilated and rotated within the posterior mediastinum, consistent with organoaxial gastric volvulus associated with a giant hiatal hernia.

Figure 3. Laparoscopic intraoperative view of the herniated gastric fundus partially enveloped by the greater omentum. The fundus, indicated by the red circle, appears engorged and displaced into the mediastinum through the diaphragmatic defect. This finding is consistent with a giant hiatal hernia complicated by organoaxial volvulus. The instruments are used for the gentle dissection and mobilization of the herniated structures.

Figure 4. Intraoperative laparoscopic view showing posterior cruroplasty. The crural fibers are clearly visualized and are being approximated with a nonabsorbable suture using extracorporeal knot tying technique. The red circle highlights the repaired diaphragmatic hiatus following reduction of the herniated stomach, as part of the hiatal hernia repair.