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Case 167

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A male patient, 52 years old, was referred to the Alfa Institute of Gastroenterology with chronic pain in the left upper abdomen for about 10 years, associated with bloating, early satiety and postprandial fullness. The patient reported diminished appetite and weight loss of approximately 20 kilograms during this period. On physical examination, the patient was slimmed, and the palpation presented a painful upper abdomen. An upper endoscopy suggested alteration of gastric morphology without alterations in the mucosa. The following imaging tests were done.

Based on the clinical picture and the images which one of the following is the most likely diagnosis and definitive therapy?

a) Organoaxial gastric volvulus / nasogastric catheterization

25%

b) Gastric cancer / surgical resection

25%

c) Chronic mesenteroaxial gastric volvulus / gastrostomy with anterior gastropexy

25%

d) Functional dyspepsia / proton pump inhibitors and dietary guidelines

25%
   

Image analysis

Image 1: Chest radiograph showing elevation of the left hemidiaphragm, when compared to the right (red lines), with marked dilation of the stomach and presence of an image of gas-like density, consistent with the colonic splenic flexure (green highlight).

 

Image 2: Contrasted CT of the abdomen showed dilation of the stomach, and the presence of a dual mixed picture, with clear transition line (red arrow) between the gastric fundus, located posteriorly, and the body, anteriorly.

 

Image 3: Contrasted radiography, supine, right posterior oblique view, showing retention of contrast in the gastric chamber and incomplete anterior rotation in the short axis of the gastric body (red arrow).

 

Image 4: Contrasted radiography, supine, left posterior oblique view, revealing altered gastric morphology: esophagogastric junction (EGJ) in a position lower than usual (yellow upper arrow), but above the pylorus (yellow bottom arrow), with posterior rotation of the gastric fundus and anterior rotation of the body, around the short axis (green arrows), which suggests the presence of incomplete mesenteroaxial volvulus. The maintenance of the anatomical relationship between the greater and lesser curvatures of the stomach (red arrows) excludes the possibility of organoaxial or mixed volvulus.

Highlights

- Suspection of chronic gastric volvulus is mainly clinical (upper gastrointestinal obstruction) and should be confirmed by imaging techniques (contrasted radiography, CT and / or endoscopy).

- Chronic volvulus are intermittent, with dynamic rotation, which makes the sensitivity of imaging tests variable, being a diagnostic challenge.

- Gastric volvulus may be secondary to hernias or other alterations that must also be addressed surgically.

- Treatment may be conservative in patients with high surgical risk, but there is a great rate of recurrence when the surgical approach is avoided.

- Acute gastric volvulus, characterized by the complete rotation, are emergencies due to the risk of ischemia, necrosis and sepsis. Mortality ranges from 30% to 50%.

References

- Savassi-Rocha PR, Coelho LGV, Moretzsohn LD, Passos MCF. Tópicos em Gastroenterologia 16: afecções menos frequentes em gastroenterologia. Rio de Janeiro: Medbook; 2007.

- Wee KL. Gastric volvulus in adults. UpToDate [internet] 2014 [access in may 2014]. Available at: http://www.uptodate.com/contents/gastric-volvulus-in-adults.

- Yeo CJ, Matthews JB, Mcfadden DW, Pemberton JH, Peters JH. Volvulus of the Stomach and Small Bowel. Shackelford’s Surgery of the Alimentary Tract. 7th edition. Philadelphia: Elsevier-Saunders; 2013.

- Channer LT, Squires GT, Price PD. Laparoscopic repair of Gastric Volvulus. JSLS. 2000 Jul/Sep;4(3): 225–230.

-  Hope, WW, Akoad M, Golub R. Gastric volvulus treatment & management. Medscape [internet] 2014 [access in May 2014]. Available at: http://emedicine.medscape.com/article/2054271-overview.

- Morelli U, Bravetti M, Ronca P, Roberto C, De Sol A, Spizzirri A, Giustozzi G, Sciannameo F. Laparoscopic anterior gastropexy for chronic recurrent gastric volvulus: a case report. JMCR [internet] 2008 Jul [access in May 2014]; 2:224. Available at: http://www.jmedicalcasereports.com/content/2/1/244

Author

André Ribeiro Guimarães, 5th  year medical student at UFMG. Email: : guimaraesandrer[at]hotmail.com

Supervisors

Marco Antônio Gonçalves Rodrigues, surgeon, member of the board of the Surgery Department of UFMG’s Medical school.

E-mail: magro.mg[at]terra.com.br

Fabiana Paiva Martins, radiologist in Hospital das Clinicas of UFMG.

E-mail: fabpaivamartins[at]gmail.com

Reviewers

Bárbara Bragaglia, Hercules Riani, Cinthia Barra, Marina Leão and Viviane Santuari Parisotto Marino.

Acknowledgements

Marcela Ferreira Nicolielo, doctor, resident in Radiology and Diagnosis by Imaging in Hospital das Clinicas – UFMG.

Luciana Costa Faria, professor of the Department of Clinics of UFMG’s Medical School.

Translated by

Bárbara de Queiroz e Bragaglia, 5th year medical student at UFMG. Email: barbara.bragaglia[at]gmail.com . 

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