93 y

1. 93 y/o malewith abd pain HPI: Onset 45 minutes after previous night’s dinner (chicken pot pie) Acute, constant, unrelenting, stabbing Diffuse but worst in mid-abdomen Non-bloody, non-bilious emesis Frequent belching No relief from Pepto-bismol

2. History PMHx: HTN Osteoarthritis Chronic periodontitis Meds: Hydrochlorothiazide Lisinopril SocHx: No tobacco/EtOH Daily treadmill

3. Exam Vitals: T 35.6 HR 119 BP 125/86 RR 20 Gen: kyphotic, elderly male in moderate distress ENT: EOMI, anicteric, conjunctiva pink, oropharynx clear Neck: supple, no adenopathy CV: RRR without murmur or gallop Lungs: CTA Abd: tender to palpation diffusely but especially in the epigastric and LUQ; no rebound or guarding; decreased BS; +distention though not tense Rectal: prostate non-tender and smooth, heme negative

4. DDx?

5. Labs 15.5 17.7 255 45.0 Alb 4.2 142 103 32 ALT 29 160 Alk Phos 106 5.3 28 1.2 T bili 1.4 Amy 162 Lip 868

7. Acute Abdominal Series Impression: There is massive gastric distention. There is air present in the colon. No evidence of small bowel obstruction. No intraperitoneal free air. There is a dilated loop of bowel projected in the epigastric region . This was not apparent on the prior studies although they include part of the abdomen. With the gastric distention, entities such as gastric volvulus or large paraesophageal hernia are to be considered . There is poor expansion of both lung bases probably related to the above finding. Rest of the lungs demonstrate no infiltrate . Cardiac shadow partly obscured. Findings discussed with ER physician at 7 p.m. 12/4/07 . It was agreed to do a CT examination .

9. CT-abd/pelvis Impression: There is a large hiatal hernia with fundus of the stomach below the left diaphragm in the abdomen, the body and antrum of the stomach are rotated and herniated into the thorax. There is massive distention of the intra-abdominal stomach with narrowing of the lumen at the antral end and gastric outlet obstruction. Findings are strongly suspicious for gastric volvulus . Small bowel and colon are nondilated. No free air . . There is small left pleural effusion. There are hepatic calcifications and gallstones. No evidence of acute cholecystitis. Other findings: No obstructing renal calculus or hydronephrosis. Atrophic pancreas. Colonic diverticula without evidence of diverticulitis. Subsegmental atelectasis both lower lobes, small subpleural nodule right lower lobe (image 39) no thoracic lymphadenopathy or pericardial effusion . Most significant findings discussed with ER physician at 8:30 p.m. 12/4/07.

10. Goals and Objectives What is volvulus? What is gastric volvulus? What happened to our patient?

11. Volvulus Definition Loop of bowel whose nose has twisted on itself Types Neonatal Small intestinal Cecal Sigmoid Gastric

12. Goals and Objectives What is volvulus? What is gastric volvulus? What happened to our patient?

13. Gastric Volvulus History (The 3 B’s) First described (Berti) 1866 First successful operation (Berg) 1896 First delineation of classic triad (Borchardt) 1904

14. Definition Abnormal rotation of the stomach more than 180 degrees Anatomy review: The Stomach

15. Classification byRotational Axis Organoaxial Rotational axis connecting GE junction to pylorus Antrum rotates opposite direction of fundus Most common type Usually associated with diaphragmatic defects Strangulation and necrosis (5-28%)

16. Classification byRotational Axis Organoaxial

17. Classification byRotational Axis Mesentericoaxial Rotational axis bisects lesser and greater curvatures Antrum rotates anteriorly and superiorly Usually incomplete and intermittent Vascular compromise uncommon Typically chronic

18. Classification byRotational Axis Mesentericoaxial

19. Classification byRotational Axis Combined Rare Usually chronic

20. Classification byEtiology Type 1 (idiopathic) Proportion of cases 2/3 Adults > Children Abnormal ligamentous laxity Gastrosplenic Gastroduodenal Gastrophrenic Gastrohepatic

22. Classification byEtiology Type 2 (congenital or acquired) Proportion of cases 1/3 Associated defects (Miller et al, 1991) Congenital defects Diaphragmatic defects 43% Gastric ligaments 32% Abnormal adhesions 9% Asplenism 5% Bowel malformations 4% Pyloric stenosis 2% Colonic distension 1% Rectal atresia 1% Complicating gastroesophageal surgery Neuromuscular disorders

23. Classification byEtiology Type 2 Secondary causes (adults) Diaphragmatic defects Gastroesophageal surgery Neuromuscular disorders Increased intra-abdominal pressure Conditions resulting in diaphragmatic elevation

24. Hiatal Hernias Anatomy review: The Diaphragmatic Hiatus Crura Central tendon LES A-ring B-ring Schatzki ring Incidence Less than 40 years of age: 10% Greater than 70 years of age: 70% Females > Males

25. Hiatal hernia Sliding GE junction above diaphragm Paraesophageal GE junction below diaphragm

26. GV: Presentation Acute Pain Intra-abdominal Intra-thoracic Distension Intra-abdominal Intra-thoracic Retching Hematemesis Borchardt triad 1. Pain 2. Retching 3. Inability to pass NG tube Chronic Pain Early satiety Dyspnea Chest discomfort Dysphagia

27. Imaging Plain film Upper GI CT

28. Treatment Name the most common modality: a. Double contrast enema b. Nasogastric decompression c. Surgery d. Endoscopic reduction 80/20

29. Goals and Objectives What is volvulus? What is gastric volvulus? What happened to our patient?

30. Back to our patient… It’s cuttin’ time: Findings Massively dialted necrotic stomach that ruptured with gentle mobilization Proximal transected margin of esophagus not viable, so transhiatal esphagectomy performed Cervical incision used for esophagostomy Procedures Exploratory laparotomy Total gastrectomy Transhiatal esophagostomy Cervical esphagostomy Witzel jejunostomy Splenectomy EBL: 1000 cc

31. Say what?!?

32. Procedure Review

33. Follow-Up

34. In Summary Gastric volvulus is a rare complication of a common condition Most common axis: organoaxial Most common cause: diaphragmatic defects ? paraesophageal hernia Early diagnosis is possible with imaging Treatment is surgical (80/20)

35. The End.