Clinical diagnosis
Case 16
Actually, the patient had the repeated gastric volvulus three times in the previous two years. She underwent endoscopic treatment that first, gastric endoscope was inserted to the descending limb of the duodenum and then, detorsion with right-directional rotation with gastric endoscope was attempted and successfully done. The oral endoscope was exchanged to the nasal-endoscope through which the guidewire was advanced to the small intestine, and a 18 F gastric tube was inserted via the guidewire and preserved for over-night. The patient discharged the following day.
【Discussion】
Stomach is originally fixed with gastro-diaphragm ligament, gastro-splenic ligament, greater omentum and lesser omentum. Gastric volvulus in childhood is caused by these ligament laxity, while gastric volvulus in adult, not only by the ligament laxity, but also by esophageal hiatal hernia (1-3). Esophageal hiatal hernia is classified into four types; type I, sliding hernia that the gastroesophageal junction migrates above the diaphragm; type II, paraesophageal hernia that the gastroesophageal junction remains in its normal anatomic position, but a portion of the fornix herniates through the diaphragmatic; type III, a combination type of sliding hernia and paraesophageal hernia: type IV, another structure (e.g. the omentum or the bowel) is present within the hernia sac along with the stomach (1). Of these types of esophageal hernia, gastric volvulus is reported to be, most often, associated with a large paraoesophageal hernia. In our case, gastric volvulus secondary to type III of paraesophageal and sliding hernia was found.
Gastric volvulus is an abnormal rotation of the stomach beyond 180 degree along with the horizontal or vertical axis (1). Namely, in organoaxial volvulus, the stomach rotates along its long axis through a line that connects the gastroesophageal junction to the pylorus (long axis of the stomach). Meanwhile, in mesenteroaxial volvulus, the stomach rotates around its short axis which is at right angles to the long axis, passing through the greater and lesser curves. In our case, mesenteroaxial volvulus was found (2, 3).
Acute gastric volvulus mostly occurs in a form of organoaxial volvulus. Surgical management should be prompt for unstable patients because gastric ischemia or perforation has a mortality of 30 % (4, 5). Surgical treatment includes gastric volvulus reduction and repair of hiatus hernia for reducing the incidence of gastric volvulus (4, 5). Our case was in a stable condition and an elderly person, and then, endoscopic repair was given. Although recurrent gastric volvulus was observed three times in our case, conservative treatment of endoscopic management would be scheduled to be given for the future recurrence if the patient condition were stable.
【Summary】
We present an eighty five-year-old female with the repeated gastric volvulus associated with esophageal hiatal hernia. Abdominal CT was useful to identify the mesenteroaxial volvulus and type III esophageal hiatal hernia. Because the patient condition was stable, endoscopic treatment was successfully given in each time. Although surgical management of gastric ligament fixation and hiatal hernia repair was considered to be a radical treatment, conservative treatment of endoscopic management was repeated in our case because of an elderly age and stable condition. Keep in mind that elderly gastric volvulus even either acute (organoaxial) or chronic (mesentroaxial) is usually associated with esophageal hiatal hernia.
【References】
1.Imperatore K, et al. Acute gastric volvulus: a deadly but commonly forgotten complication of hiatal hernia. Autops Case Rep. 2016; 6: 21–26.
2.Le Blanc I, et al. Gastric volvulus secondary to para-esophageal and sliding hiatal hernias. Ann Chir. 1991; 45:42-45
3.Bhushan N, et al. Gastric volvulus. Indian J Surg 2010; 72:163–164
4.Light D, et al. The threatened stomach: management of the acute gastric volvulus. Surg Endosc.. 2016 ;30:1847-1852. doi: 10.1007/s00464-015-4425-1. Epub 2015 Aug 15
5.Bedioui H et al. Gastric volvulus: diagnosis and management. Presse Med. 2008; 37: e67-76. Epub 2007 Jun 22.
2016.7.27
COPYRIGHT © SEICHOKAI YUJINKAI. ALL RIGHTS RESERVED.