Joseph G H Lee1, Estello Nap-Hill1, Brian B Bressler1. 1. Department of Medicine, Division of Gastroenterology, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.
A 68-year-old female with history of recent coronary artery bypass graft surgery presented to hospital with sudden onset chest pain during dinner. Initial high-sensitivity troponin (normal <9 ng/L) was 15 ng/L increasing to a modest peak at 115 ng/L while her ECG was consistently normal. She was treated as a non-ST elevation myocardial infarction with stenting of a stenotic distal graft anastomotic site. Post-procedure, her severe retrosternal chest pain recurred. Gastroenterology was consulted for dysphagia and odynophagia noted to be present concurrent with her initial chest pain presentation.An urgent CT scan of the abdomen and pelvis revealed acute mesenterico-axial gastric volvulus (Figures 1–3), a rarer form of gastric volvulus compared to its organo-axial counterpart (1). After a failed nasogastric decompression, an emergent upper endoscopy was attempted and demonstrated extensive mucosal necrosis (Figure 4) but was unsuccessful in relieving the volvulus. She then underwent overnight surgery, which showed gastric volvulus with contained perforation and 50% necrosis of the stomach with sparing of the cardia and antrum. This resulted in a subtotal gastrectomy and hiatus hernia repair. She then recovered in the ICU.
Figure 1.
Coronal CT image demonstrating gastric volvulus with an intrathoracic stomach (yellow arrow) and suspected site of gastric perforation (orange arrow).
Figure 4.
Endoscopic image showing extensive gastric mucosal necrosis with an ill-positioned nasogastric tube (blue arrow).
Coronal CT image demonstrating gastric volvulus with an intrathoracic stomach (yellow arrow) and suspected site of gastric perforation (orange arrow).Sagittal CT image of gastric volvulus showing the heart (red arrow), intrathoracic stomach (yellow arrow), and suspected site of gastric perforation (orange arrow).Axial CT image showing the heart (red arrow) and intrathoracic stomach (yellow arrow).Endoscopic image showing extensive gastric mucosal necrosis with an ill-positioned nasogastric tube (blue arrow).Acute gastric volvulus is a rare but potentially life-threatening condition that may be an easily missed diagnosis (2). It can encompass the Borchardt’s triad of vomiting, epigastric pain, and inability to insert a nasogastric tube (3). We report a case of mesenterico-axial gastric volvulus presenting as acute coronary syndrome with radiographic and endoscopic images. Individuals presenting with chest pain should be evaluated with gastric volvulus in the differential diagnosis.
Figure 1.
Figure 4.