Unusual epigastric pain and retching

Mrs. C, 91 years old, lives with her 96-year-old husband in a nursing home. She enjoys reading and spending time with friends and family, especially her husband. I monitor her regularly for a number of medical problems, including hypertension, depression, osteoporosis, and hypothyroidism. Fortunately, all are well-controlled on medication.

RECURRENT GI SYMPTOMS

During the past six months, Mrs. C had visited the emergency department (ED) twice and was admitted both times for overnight evaluation of abrupt-onset severe epigastric pain and retching. The differential diagnosis for these symptoms is extensive. Common causes include cholelithiasis, peptic ulcer disease, MI, and pancreatitis. The diagnostic workup involved Helicobacter pylori testing, serum amylase and lipase determinations, complete blood count, liver enzymes, ECG, and cardiac enzymes, all of which were unremarkable.

Upper endoscopy demonstrated a large diaphragmatic hernia and mild gastritis. A CT of the abdomen and pelvis (obtained after Mrs. C's symptoms had improved) was normal, and ultrasound of the abdomen did not reveal any gallstones. The gastroenterologist attributed her recurrent epigastric pain and retching to the hiatal hernia and gastritis noted on endoscopy.

Mrs. C was started on a proton-pump inhibitor and given IV fluids. Each time, following a brief hospital stay, she was discharged with a presumptive diagnosis of epigastric pain and gastritis.

The true diagnosis of Mrs. C's condition was confirmed when she returned to the ED for a third episode of epigastric pain.




Click "Next" to find the answer.

DISCUSSION

A CT scan of the abdomen performed while she was retching and in severe pain revealed that Mrs. C had gastric volvulus. Gastric volvulus is a rare condition in which the stomach twists on itself, rotating more than 180°. It is almost always associated with a large diaphragmatic hernia, most often a paraesophageal hiatal hernia in adults older than 50. Males and females are affected equally. Abnormal laxity of the suspensory ligaments of the stomach may be a predisposing factor. Gastric volvulus can occur rarely in children with congenital diaphragmatic defects.

There are two types of gastric volvulus. Type 1 is the more common. It is organoaxial, with the twist occurring along the line connecting the gastric cardia and pylorus. In type 2, the twist occurs along a line between the lesser and greater curvatures of the stomach.

Patients with gastric volvulus often experience a trio of symptoms known as Borchardt's triad, which consists of acute-onset abdominal pain, retching without vomiting, and inability to pass a nasogastric tube. Once symptoms have raised suspicion of gastric volvulus, the diagnostic workup includes imaging studies, such as x-ray, an upper GI series, or CT scan.

Patients with chronic gastric volvulus often have vague symptoms of intermittent epigastric pain and postprandial fullness. Such nonspecific symptoms in combination with a rare diagnosis can lead to delay in identification.

THE ONLY TREATMENT OPTION

Gastric volvulus can be fatal. Mortality ranges from 15%-20% in uncomplicated cases but rises to 40% when patients require emergency surgery and 60% if there is strangulation resulting in gangrene. The only treatment is surgery.

Our patient had type 1 gastric volvulus. She underwent a laparoscopic reduction and anterior gastropexy with good results. Since then, Mrs. C has not made any return visits to the ED for abdominal pain. She continues to enjoy reading and spending time with her husband.

Dr. Schlam is assistant director of the Mountainside Family Residency Program in Verona, N.J.