Gastric volvulus.A 57-year old woman who presented with a six-hour history of severe epigastic pain radiating through to the back, associated with nausea and a desire to vomit - she was unable to vomit. The plain chest radiograph showed a massive air bubble in the chest and a diagnosis was made of a gastric volvulus. A nasogastric tube was passed. This lead to the passage of a large volume of air and immediate symptomatic relief. A contrast study showed that most of the stomach was in the right chest and the nasogastric tube could not be passsed below the diaphragm.
The patient underwent an attempted laparoscopic reduction and repair of the volvulus. Whilst the stomach could be pulled back into the abdominal cavity laparoscopically, repair of the diaphragmatic defect was not possible because the large left lobe of the liver prohibited an adequate display of the esophageal hiatus. The patient was obese and had a lot of fatty infiltration of the liver. The procedure was completed by open surgery. The esophageal hiatus was narrowed and a Nissen fundoplication performed.
The third photograph was taken one month after the procedure and shows the stomach in its correct position below the diaphragm.
Comment: gastric volvulus is an uncommon problem, usually occurring in the elderly. An acute volvulus is a surgical emergency and a laparoscopic approach is often successful in reducing the volvulus and repairing the hiatal defect.
Teague WJ, Ackroyd R, Watson DI, Devitt PG. Changing patterns in the management of gastric volvulus over 14 years. Br J Surg 2000 Mar;87(3):358-61.
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