An Unusual Presentation of Gastric Volvulus in an Older Woman
In older populations, atypical presentation of diseases is more common and less frequent causes of chest pain need to be considered, especially for patients who fail to respond to standard treatment. We present a case of an older woman with cardiac disease whose clinical presentation suggested an acute coronary syndrome, but whose pain was ultimately determined to be caused by a gastric volvulus requiring surgical correction. We also review the differential diagnosis of chest pain and the diagnosis and mechanism of gastric volvulus.
Ms. W, an 81-year-old woman with coronary artery disease, presented to the Emergency Department (ED) with several hours of chest pain. The pain began late morning and was constant, stabbing, and nonreproducible with 10/10 intensity. It radiated to her left arm and was associated with nausea, diaphoresis, and shortness of breath. The patient had no palpitations or vomiting. She had no similar chest pain in the past and had limited relief in the ED with sublingual nitrates and morphine sulfate.
Ms. W’s past medical history was significant for coronary artery disease, hypertension, dyslipidemia, and borderline diabetes. She had suffered a myocardial infarction and undergone 4-vessel coronary artery bypass graft (CABG) surgery 12 years prior to admission. Ms. W is fully independent in basic and instrumental activities of daily living. The patient had discontinued use of tobacco many years earlier.
Her exam was unremarkable except for a previously known systolic heart murmur. Laboratory values including cardiac enzymes were normal, and the electrocardiogram showed an old right bundle branch block. The patient was initially treated for unstable angina with heparin and beta-blockers but her pain did not improve. Computed tomography (CT) scan of the chest revealed gastric volvulus.
Differential Diagnosis of Chest Pain
Chest pain is a frequent reason for patients to seek medical attention. It is classified as chest wall, musculoskeletal, pulmonary, gastrointestional, neurological, or cardiovascular (Table).
Herpes zoster is a common cause of cutaneous pain associated with vesicular rash. It is described as sharp, burning, or tingling and usually follows a dermatomal distribution.1
Musculoskeletal pain, on the other hand, is localized, reproducible, and can be exacerbated by deep breaths and movement. Costochondritis and rheumatic diseases (ie, fibromyalgia and rheumatoid arthritis) are common examples. An oncolologic cause like neoplasm or a hematologic cause such as sickle cell disease can have similar presentation. A neurological cause of chest pain is radicular cervical spine disease.
Chest pain secondary to pulmonary etiologies can be associated with shortness of breath (ie, spontaneous pneumothorax) or tachycardia (ie, pulmonary embolism). Pneumonia with significant pleural effusion or empyema2 and pleurisy from autoimmune diseases or infectious causes (ie, viral or tuberculosis) can also manifest as chest pain.
Esophageal spasm and gastroesophageal reflux disease can mimic anginal pain.3 Additionally, referred visceral pain of peptic ulcer disease, pancreatitis, and cholecystitis can be misleading.
Myocardial ischemia and aortic dissection are, however, the most worrisome causes of chest pain.4 The former is usually substernal, radiating to the left arm or jaw along with diaphoresis, nausea, vomiting, dyspnea, and palpitations. Aortic dissection is classically described as a tearing migratory pain radiating to the back. It can present with acute aortic regurgitation and heart failure symptoms.
Severe aortic stenosis can manifest with progressive anginal chest pain, dyspnea, and syncope.5 Pericarditis presents as sharp, pleuritic pain of sudden onset over the anterior chest exacerbated by inspiration and lying down.6 Myocarditis may present with both cardiac and systemic symptoms such as fever, myalgias, and muscle tenderness.7
Gastric volvulus is an abnormal rotation of the stomach creating a closed loop that can become incarcerated or strangulated. The term volvulus is derived from the Latin volvere, meaning to turn or roll. Paré first described acute gastric volvulus in 1579, in a patient who sustained a diaphragmatic injury from a sword wound.8 Gastric volvulus is a rare condition. A recent review series in Greece revealed only 21 patients with the condition over a 10-year period.9 Males and females are equally affected.
Classification of gastric volvulus depends on the axis around which the stomach rotates. In organoaxial volvulus, the stomach rotates around the axis that connects gastroesophageal junction (GEJ) to pylorus. The antrum rotates in the opposite direction to the fundus. This is the most common type and is usually associated with a diaphragmatic defect. Up to 28% of organoaxial gastric volvulus will result in strangulation and necrosis. Mesenteroaxial volvulus involves an anterior and superior rotation of the antrum around the axis that bisects both the lesser and greater curvatures. This type of volvulus is less common and is usually found in chronic gastric volvulus.10,11
Gastric volvulus is also classified based on etiology and the anatomical position of the hiatal hernias with respect to the GEJ and diaphragmatic defect. Hiatal hernias are classified into four types. Type I, or sliding hernia, is presumed to be due to laxity of the ligaments holding the stomach in place (ie, gastrosplenic, gastroduodenal, and gastrophrenic ligaments), which allows the movement of the GEJ cephalad. Type I is the most common cause in adults and accounts for two-thirds of cases. Type II, or true paraesophageal hernia, is less common and is due to either congenital or acquired defects. The GEJ remains in its normal anatomical position while the fundus herniates anteriorly through the gastrophrenic ligament. Congenital defects include diaphragmatic defect, loose gastric ligaments, or abnormal attachments or adhesions. Acquired defects in adults are mostly due to diaphragmatic defects secondary to trauma, gastroesophageal surgery, post-CABG, or neuromuscular disorder such as myotonic disease. Other causes of acquired defects are increased intra-abdominal pressure from abdominal tumors or conditions that cause diaphragmatic elevation such as left lung resection or phrenic nerve palsy. Type III is a combination of Types I and II, and Type IV involves another intra-abdominal organ (ie, colon, spleen). Types II and IV are more prevalent in elderly patients and likely represent a longstanding hiatal defect.10,11
Gastric volvulus can be acute or chronic. Acute gastric volvulus is a medical emergency with a reported mortality rate of up to 50% if left untreated.12 It often presents with pain followed by progressive distension and nonproductive retching and may be associated with hematemesis secondary to mucosal ischemia.13 Intrathoracic volvulus can manifest as a sharp chest pain radiating to the left side of the neck, shoulder, arm, or back with minimal abdominal findings. Intra-abdominal volvulus presents with severe epigastric or left upper quadrant pain and upper abdominal distension and tenderness. Chronic gastric volvulus often has nonspecific symptoms such as early satiety, dysphagia, or intermittent epigastric pain.11
Diagnosis of acute volvulus can be made by upper gastrointestingal series, CT scan, chest radiograph, or abdominal radiograph. The Borchardt triad (pain, retching, and inability to pass a nasogatric tube) can be diagnostic in 70% of cases.12 Those who have undergone cardiothoracic surgery or other surgical manipulation of their diaphragm are at greater risk. Chronic volvulus is often diagnosed by barium studies or with endoscopy.
Treatment of gastric volvulus is surgical, using either the laparoscopic or open approach.14 The open laparotomy surgical approaches include reduction of the herniated stomach into the abdomen (hernia sac dissection if manual reduction is unsuccessful); herniotomy (complete excision of the hernia sac from the mediastinum); herniorrhaphy (closure of the hiatal defect); Nissen fundoplication (an antireflux procedure that also helps hold stomach and esophagus intra-abdominally); and gastropexy (attachment of the stomach subdiaphragmatically to prevent reherniation). Two gastrostomy tubes are sometimes used when the patient is deemed too frail to undergo a complete laparoscopic paraesophageal repair. They help secure the stomach to the anterior abdominal wall and reduce risk of organoaxial rotation. Laparoscopic approach involves placement of the scope through the umbilicus and the stomach is reduced and reoriented with a grasper. A gastrostomy tube is placed to provide postoperative decompression and prevent recurrence. However, the laparoscopic approach in older persons is associated with more complications in patients over 75 years old.15 Based on a report by Hashemi et al,16 the incidence of recurrence is 42% with the laparoscopic approach versus 15% with the open approach.
Outcome of the Case Patient
Ms. W underwent a laparotomy with a reduction of the gastric volvulus and repair of paraesophageal hernia via Nissen fundoplication. A swallow evaluation was done postoperatively and she was started on a clear diet. Her diet was advanced to soft solids, and she was counseled about the possibility of feeling nauseous and requiring antiemetic medications for a short period. The patient tolerated oral intake and she was discharged home.
Acute gastric volvulus is a rare condition with a high mortality rate if left untreated. This case demonstrates the need for a high index of suspicion for gastric volvulus. Even in the presence of cardiac risk factors and history of heart disease, acute gastric volvulus should be considered, especially if the patient has a hiatal hernia. Acute gastric volvulus often presents with pain followed by progressive distension and nonproductive retching. Chronic gastric volvulus often has nonspecific symptoms such as early satiety, dysphagia, or intermittent epigastric pain. Diagnosis of volvulus can be made via upper gastrointestinal series, CT scan, chest radiograph, abdominal radiograph, or barium swallow.
The authors report no relevant financial relationships.