An 86-year-old man presented with a 3-day history of abdominal distension, epigastric
pain, and vomiting. Computed tomography showed gastric distension, with part of the
gastric body herniating into the thoracic cavity, and a paraesophageal hernia. These
findings were consistent with a mesenteroaxial gastric volvulus ([Figure 1]). The patient was significantly dehydrated and further tests revealed that he had
renal failure, metabolic acidosis, and cardiac arrhythmias. Immediate surgical intervention
was considered to be an extremely high-risk option, so the volvulus was reduced endoscopically.
Figure 1 a Computed tomographic views showing gastric distension. b Part of the gastric body can be seen to be herniating into the thoracic cavity.
After insertion of the endoscope and gentle air insufflation, the volvulus was reduced,
revealing erythematous mucosa with multiple ischemic-appearing ulcers throughout the
gastric body ([Figure 2]). Reduction of the volvulus was confirmed by abdominal radiography, and the patient’s
hemodynamic status improved with supportive measures. One week after this endoscopic
reduction the gastric volvulus recurred. However, the intervening week had allowed
time for the patient to stabilize and he presented a lower surgical risk. He underwent
successful reduction of the hernia, gastropexy, and a Nissen fundoplication.
Figure 2 Endoscopic view of the gastric body, showing ischemic ulcers, after reduction of the
gastric volvulus.
Gastric volvulus is a rotation of the stomach that results in a closed-loop obstruction
[1]. This can present with either acute or chronic symptoms, depending on the degree
of obstruction [2]. In adults it is usually associated with a paraesophageal hernia [3]. Gastric volvulus can be described according to its location relative to the diaphragm
and its axis of rotation as either ”organoaxial” or ”mesenteroaxial” [4]. Without prompt treatment, the incidence of ischemic necrosis in an acute volvulus
is significant, resulting in a mortality of 30 % - 50 % [2]. Endoscopy in our patient demonstrated ischemic ulcers, emphasizing the severity
of his presentation. The treatment of choice is surgical reduction, either open or
laparoscopic [5]. However, in the emergency setting, the mortality associated with surgery can be
high and endoscopic reduction should be considered to allow time for the patient to
be adequately resuscitated.
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