CT Case 072
A 78-year-old lady from a nursing home is brought into ED by ambulance with acute upper abdominal pain, vomiting, and abdominal distension.
She suffers from dementia and has a previously diagnosed large hiatus hernia. She has had previous similar presentations with abdominal pain and distension.
Describe and interpret the CT images
This is quite a difficult case to conceptualise on static images. We can see marked gastric dilatation, indicating obstruction. The distended stomach occupies nearly the entire upper abdomen.
There is mesenteroaxial rotation of the stomach*, such that the gastric fundus has rotated postero-inferiorly and the antrum/pylorus has rotated antero-superiorly with part of the stomach herniating through into the mediastinum. There is obstruction at the diaphragmatic hiatus.
*Mesenteroaxial rotation, as in this case, is when the stomach rotates along its transverse axis.
Clinical Pearls
This is a case of gastric volvulus.
This occurs when the stomach rotates greater than 180 degrees along its transverse or longitudinal axis. Mesenteroaxial rotation, as in this case, is when the stomach rotates along its transverse axis.
Patients will present with abdominal pain, distension and vomiting. Sequelae include stomach strangulation, necrosis, perforation and shock.
10-30% of cases of gastric volvulus are considered primary and are due to laxity of the stomach’s ligamentous attachment.
Other anatomical abnormalities, such as diaphragmatic hernia (as in this case) can predispose to gastric volvulus.
Management is surgical, with untwisting of the volvulus intra-operatively.
Conservative management, with endoscopic decompression and percutaneous gastrostomy tube to gastropexy the stomach to the abdominal wall, has been successful in stable high-risk elderly patients.
By the time of ED presentation this patient had perforation and establish multi-organ dysfunction. She was managed with NGT insertion and comfort measures.
References
- Lourenço S, Pereira AM, Guimarães M, Nora M. Gastric Volvulus: A Complication of Hiatal Hernia. Cureus. 2020 Oct 24;12(10):e11123.
- Lopez PP, Megha R. Gastric Volvulus. StatPearls
- Winslow S. Annals of B Pod: Gastric Volvulus. Taming the SRU
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Dr Leon Lam FRANZCR MBBS BSci(Med). Clinical Radiologist and Senior Staff Specialist at Liverpool Hospital, Sydney
Sydney-based Emergency Physician (MBBS, FACEM) working at Liverpool Hospital. Passionate about education, trainees and travel. Special interests include radiology, orthopaedics and trauma. Creator of the Sydney Emergency XRay interpretation day (SEXI).
Provisional fellow in emergency radiology, Liverpool hospital, Sydney. Other areas of interest include paediatric and cardiac imaging.
Emergency Medicine Education Fellow at Liverpool Hospital NSW. MBBS (Hons) Monash University. Interests in indigenous health and medical education. When not in the emergency department, can most likely be found running up some mountain training for the next ultramarathon.