SMJ 2003 48(4): 123-124
David A. Cairns MBChB MRCS Ed, Senior House Officer
Mike Hulme-Moir MD FRCS, Specialist Registrar
University Department of Surgery, The Royal Infirmary of Edinburgh, Edinburgh. EH3 9YW
Correspondence to: davidcairns@blueyonder.co.uk
Abstract
Gastric volvulus is a rare condition which usually presents with intermittent abdominal pain. It is typically associated with a paraoesophageal hiatus hernia and may present with acute strangulation or perforation. The mortality associated with an acutely obstructed volvulus may be up to 50%. Correspondingly, this condition is regarded as a surgical emergency. We present the history of a patient with an acute gastric volvulus and unexplained hypotension.
Keywords: Gastric Volvulus, Hiatus Hernia, Splenic Vessels
Introduction
Gastric volvulus is a rare condition which typically presents with
intermittent episodes of abdominal pain.1,2 The volvulus occurs
around an axis made by two fixed points, organo-axial or mesentero-axial, and is
typically associated with a paraoesophageal hiatus hernia. Increased pressure
within the hernial sac associated with gastric distension can lead to ischaemia
and perforation.3,4 Acute obstruction of a gastric volvulus is thus a
true surgical emergency.
Case report
A 71 year old man with a past medical history of alcohol abuse was admitted to our hospital as an emergency. He had no significant medical history and had been well prior to admission.
He complained of acute severe epigastric pain radiating to the left shoulder which had started one hour previously. There was no history of vomiting or haematemesis. On arrival to hospital he was hypotensive (blood pressure 80/50 mmHg), tachycardic (pulse rate 120 beats per minute) and was noted to have marked abdominal distension. His initial respiratory rate was 40 breaths per minute with an Oxygen saturation of 64% breathing room air.
Intravenous fluid resuscitation with 1 litre of crystalloid resulted in an improvement of blood pressure to 130/70 mmHg and reduction in pulse rate to 100 beats per minute. A nasogastric tube was inserted with some difficulty and 1 litre of non-bile stained fluid was aspirated. Post-aspiration there was an immediate improvement in respiratory status with the rate decreasing to 24 breaths per minute and Oxygen saturation increasing to 89% on 6 litres of Oxygen.
An erect chest X-ray and a supine abdominal film were obtained and these are shown in Figures 1 and 2. Figure 1 demonstrates a pneumoperitoneum and hiatus hernia. Gross gastric dilatation is seen Figure 2.
A provisional diagnosis of
a perforated viscus was made and the patient was transferred to the high
dependency unit for further resuscitation prior to surgery. Soon after arriving
in HDU he had a further episode of hypotension (blood pressure 90/60 mmHg), and
a bradycardia (pulse rate 30 beats per minute) requiring further intravenous
fluids and atropine.
An emergency laparotomy was performed through an upper midline incision. Upon entering the peritoneal cavity a total of 2.5 litres of blood and gastric contents were removed. Inspection of the viscera revealed a mesentero-axial gastric volvulus with a paraoesophageal hiatus hernia and a large perforation on the lesser gastric curve. Closer inspection also revealed avulsion of the splenic vessels and continuing haemorrhage from the splenic pedicle.
Haemostasis was achieved by undersewing the splenic pedicle followed by splenectomy. The volvulus was manually reduced and the paraoesophageal hernia repaired by means of a posterior cruroplasty using interrupted 1 prolene sutures. Wedge resections of the gastric fundus were performed to repair the area of perforation using a two layer closure technique with continuous 4/0 PDS. A thorough lavage of the abdominal cavity was performed with several litres of saline prior to closure. Two large drains were inserted to drain the left upper quadrant and lesser curve regions respectively, while the nasogastric tube was noted to be in a good position at the end of the procedure. The total blood loss during surgery was 3 litres, requiring transfusion of 11 units of blood, 4 units of platelets and 4 units of fresh frozen plasma.
Post-operatively the patient was transferred to the intensive care unit for ventilation and inotropic support. He was extubated on the third post-operative day and was discharged to the high dependency unit the following day. Oral diet was slowly re-introduced after a period of nasogastric feeding with no obvious episodes of aspiration. However, recovery from surgery was complicated by alcohol withdrawal and a basal pneumonia. Despite slow initial improvement and treatment with intravenous antibiotics and chest physiotherapy his respiratory status continued to deteriorate and he died after cardiac arrest on the 16th post-operative day. A post-mortem examination was not performed.
Discussion
Perforation of an obstructed gastric volvulus is associated with high morbidity and mortality.1,2,4 Gastric volvulus has previously been reported in association with a wandering spleen, however we believe this is the first report of a volvulus with avulsion of the splenic vessels.5
This case provides further evidence of the need for immediate surgical intervention in an acute gastric volvulus. Avulsion of the splenic vessels should be considered as a cause of hypotension in any patient presenting with an acutely obstructed volvulus. We suggest that this association also adds weight to the case for prophylactic repair of a chronic volvulus.
References
Wastell
C, Ellis H. Volvulus of the stomach. A review with a report of 8 cases.
British Journal of Surgery 1971; 58(8): 557-62.
Milne
LW, Hunter JJ, Anshus JS, Rosen P. Gastric volvulus: two cases and a review
of the literature. Journal of Emergency Medicine 1994; 12(3): 299-306.
Farag
S, Fiallo V, Nash S, Navab F. Gastric Perforation in a case of gastric
volvulus. American Journal of Gastroenterology 1996; 91(9): 1863-4.
Babb
RR, Peck OC, Jamplis RW. Gastric volvulus and obstruction in paraoesophageal
hiatus hernia. A surgical emergency. American Journal of Digestive diseases
1972; 17(2): 119-28.
Uc A, Kao SC, Sanders KD, Lawrence J. Gastric volvulus and wandering spleen. American Journal of Gastroenterology 1998; 93(7): 1146-8.