European Journal of Radiology Extra 73 (2010) e21–e23
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Triple fluid level due to gastric volvulus complicating bilateral paraesophageal hernia: Case report Gülen Demirpolat a,∗ , Tuba Balakan a , U˘gur Dal a , Ertan Bulbuloglu b , Gulgun Demirpolat c a b c
Kahramanmaras Sutcu Imam University, School of Medicine, Radiology Department, Kahramanmaras, Turkey Kahramanmaras Sutcu Imam University, School of Medicine, General Surgery Department, Kahramanmaras, Turkey Ege University, School of Medicine, Radiology Department, Izmir, Turkey
a r t i c l e
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Article history: Received 14 June 2009 Received in revised form 11 August 2009 Accepted 25 August 2009
Keywords: Paraesophageal hernia Gastric volvulus Gastric emphysema
a b s t r a c t Paraesophageal hernia is the second most type of hiatal hernias. It is a known predisposing factor for gastric volvulus. When acute gastric volvulus occurs, early diagnosis before strangulation and incarceration will be life-saving. We are presenting a case with paraesophageal hernia and gastric volvulus with unusual radiologic findings. The patient came to emergency room with acute symptoms. The diagnosis was made with multidetector computed tomography (MDCT). Three spherical gas bubbles were seen in the chest X-ray. Two of them were intrathoracic and the third one was intraabdominal. MDCT showed that most of the stomach was in the chest alongside the esophagus. Gas in the portal veins and gastric wall was also seen. The patient was treated with surgery. © 2009 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Paraesophageal hernias form approximately 5% of all hiatal hernias [1]. Gastric volvulus is the most frightening complication of paraesophageal hernias. It has 42–56% mortality rate [2]. It may arise with acute or chronic symptoms. When strangulation and incarceration occur early diagnosis and emergent treatment are mandatory. In this case report we are presenting a case with unusual radiographic presentation. After shortly discussing the symptoms and radiological findings of paraesophageal hernias and gastric volvulus, the major advantages of MDCT in the diagnosis is emphasized. 2. Case report A forty-eight-year-old man presented to the emergency department with an acute onset of severe nausea, kecking and nonradiating sharp epigastric pain of 5–6 h duration. He did not have emesis. He denied use of any non-steroidal anti-inflammatory drugs and alcohol. On physical examination, he was found to be afebrile, with stable vital signs. He was in mild distress however
∗ Corresponding author. Tel.: +90 0533 8127158/90 0344 2257575; fax: +90 0344 2212371. E-mail addresses:
[email protected] (G. Demirpolat),
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it progressed to severe distress while the laboratory tests and radiological examinations were conducted. Abdominal examination revealed severe epigastric tenderness with normoactive bowel sounds. No peritoneal signs were noted. Nasogastric tube could not be passed down to the stomach. Abdominal radiography showed bilateral large paramediastinal spherical gas bubbles due to air-fluid levels. Fundal gas shadow was located normally under the left hemidiaphragm. There was paucity of bowel gas. Endoscopy was performed but the endoscope could not be moved into the stomach. Small mucosal haemorrhages were seen under limited examination. The patient was examined with contrast-enhanced multi-detector computed tomography (MDCT) with multiplanar reconstructions. Three spherical gas bowels were seen on the CT scanograms (Fig. 1a and b). On axial and reformatted images the distal stomach herniation into the right and left cardiophrenic area alongside the esophagus was demonstrated (Fig. 2). Gastroesophageal junction was in normal location. The pylorus was replaced more anteriorly and superiorly (Fig. 3). Gastric wall emphysema and portal venous gases were detected (Fig. 4). Abdominal free air, pneumothorax, peritoneal and pleural fluid were not seen. Bilateral lung atelectasis nearby the intra-thoracic stomach was detected. The diagnosis of bilateral paraesophageal hiatal hernia and mesenteroaxial volvulus was made. Gastric wall necrosis was suggested due to gas in the portal venous system and gastric wall. Laparoscopy showed that gastroesophageal junction was close to the pylori; the stomach was rotated around its short axis and herniated through the widened esophageal hiatus. There was a 3 cm diameter necrosis in the corpus–fundus junction. The stomach was replaced into the abdomen and necrotic area was
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G. Demirpolat et al. / European Journal of Radiology Extra 73 (2010) e21–e23
Fig. 1. Three spherical gas bubbles are seen on AP (a) and lateral (b) thoracoabdominal CT scanograms. Fig. 3. Axial image demonstrating that pylorus is localized more anteriorly and superiorly and inserted nearby the esophagogastric junction.
Paraesophageal hernia may or may not be symptomatic. Recurrent nausea, vomiting, retching, radiating chest pain not relieved by antacids and symptoms due to relapsing chest infection can occur [3]. It can be associated with more serious complications. Intrathoracic incarceration and strangulation are the most frightening serious complication of paraesophageal hernia, which develops when gastric volvulus occurs [1]. The peak age group of occurrence is in the fifth decade [2]. Gastric volvulus can be acute, fulminant or chronic intermittent [3]. Since the symptoms may be non-specific, the diagnosis might be missed or delayed [2]. Rotation of the stomach more than 180◦ leads to closed loop obstruction symptoms. Acute gastric volvulus is a life-threatening disease and requires rapid recognition and
Fig. 2. Partial stomach herniation alongside the esophagus into the right and left cardiophrenic sinus is seen on coronal reformatted images.
resected. The widened hiatus was repaired and Nissen fundoplication and gastropexy were done. 3. Discussion Hiatal hernias are classified according to location of the gastroesophageal junction and accompanying migrating abdominal organs with the stomach. In paraesophageal hernia, there is a focal defect in the anterior and lateral aspect of the phrenicoesophageal membrane, the GEJ remains at normal position and widened hiatus permits the stomach to protrude into the chest [1]. The stomach resides in the paraesophageal location. As the hiatus widens, increasing amounts of the stomach is pulled towards into the chest.
Fig. 4. Axial images showing air in the gastric wall and portal veins.
G. Demirpolat et al. / European Journal of Radiology Extra 73 (2010) e21–e23
emergent surgical treatment. It has a broad spectrum of symptoms. Borchardt’s triad is reported in 70% of cases. It presents clinically with epigastric pain radiating into the back and/or left thoracic area or left upper abdominal quadrant, retching and difficulty in passing a nasogastric tube [1]. It may mimic gastric distension, cardiopulmonary diseases, cholecystitis, gastric and duodenal ulcer and pancreatitis. Gastric volvulus is classified into three types according to rotation axis. In the anterior organoaxial rotation (59% of all gastric volvuli), mobile greater curvature moves anteriorly and superiorly and in 180◦ organoaxial rotation, mirror image of stomach is created with convex greater curvature located above and to the right of concave lesser curvature. The stomach flips upward along its long axis. This type of rotation does not have risk of ischemia. Obstruction, however, can occur [1,2,4]. Rotation of stomach is along the short axis (perpendicular to organ’s long axis) in the mesenteroaxial rotation (29%). Mobile antrum and duodenum are moved anteriorly and superiorly nearby the anterior–lateral side of the esophagus. The gastric cardia and the esophagogastric junction remain at normal location. Greater curvature remains on the left. Gastric fundus and antrum may be in reversed positions [4]. Mixed type volvulus is less frequent than the others (12%) [5]. Mesenteroaxial and mixt type volvuli often present acutely in severe cases. Closed-loop obstruction, strangulation and gastric ischemia can occur. Our case had come with an acute onset of severe nausea, kecking and nonradiating sharp epigastric pain. Multislice CT showed bilateral paraesophageal gastric herniation and more anteriorly and superiorly localized pylori that settled nearby the esophagogastric junction. Mesenteroaxial volvulus and hiatal hernia were leading to gastric outlet obstruction, gastric emphysema and gas in portal veins. Gastric emphysema and gas in portal veins were due to incarceration. On chest radiography, hiatal hernias are shown as retrocardiac masses with or without air-fluid level. Accurate diagnosis is made with upper gastrointestinal series. The gold standard in volvulus diagnosis is barium swallow [2]. Abrupt disruption of the esophageal or gastric barium swallow, abnormal rotation of the rugal folds and intra-thoracic placement of the stomach are diagnostic evidences of volvulus [6]. Because of often confusing clinical nature of chronic volvulus a contrast exam is often delayed until late in the course or until the volvulus has become acutely incarcerated. These patients, however, often have chest radiographs from which the diagnosis can be suspected before an acute incarceration develops. When gastric volvulus herniates into the chest, two basic radiographic patterns may be seen. Early, there are two large airfluid levels. The one in the retrocardiac mediastinum represents the dilated, herniated distal stomach with partial or complete obstruction of its outlet. The second, beneath the left hemidiaphragm, represents an air-fluid level in the normally positioned fundus which may partially be obstructed at the inlet to the twisted herniated segment. At this time, symptoms suggesting gastric outlet obstruction usually occur. When the rotation increases so that both the inlet and outlet of the rotated and herniated distal stomach
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become obstructed, the retrocardiac air-fluid level is replaced by a homogenous soft tissue mass, the antrum filled with fluid [7]. In our case three air-fluid levels were seen due to bilateral paraesophageal stomach herniation. When the patients’ clinical findings are severe and he/she cannot tolerate scopic study, MDCT with two- and three-dimensional reformatted images should be preferred. Multiplanar reformatted views of the stomach reveal the complex anatomy clearly. Delay in the diagnosis of volvulus leads to left gastric artery thrombosis, strangulation, gastric necrosis and perforation. Strangulation occurs in 5–28% of patients and mortality is 30–50% for acute gastric volvulus and 60% if strangulation and infarction occurs. Gastric pneumatosis which may be due to mucosal ischemia, increased intraluminal pressure, or severe vomiting can be easily detected with MDCT images [8]. The gold standard in the treatment of volvulus is open laparotomy with detorsion and prevention with anterior gastropexy [1]. However, many centers use laparoscopic reduction and repair due to its low morbidity and significantly shorter hospital stay [9,10]. 4. Conclusion Gatric volvulus is a known life-threatening complication of the paraesophageal hernia. Its symptoms can be intervening with upper gastrointestinal system and cardiopulmonary diseases and patients do not always exhibit unstable vital signs and distressed appearance. When it is suspected, urgent diagnostic research suitable for the patient’s status may prevent expending time and possible mortality. For patients in advanced stages who cannot tolerate barium studies, prompt diagnosis can be accurately achieved with MDCT. 5. Conflict of interest No financial interest. References [1] Abbara S, Kalan MM, Lewicki AM. Intrathoracic stomach revisited. AJR 2003;181:403–14. [2] Chau B, Dufel S. Gastric volvulus. Emerg Med J 2007;24:446–7. [3] Shivanand G, Seema S, Srivastava DN, et al. Gastric volvulus: acute and chronic presentation. Clin Imaging 2003;27:265–8. [4] Sevcik WE, Steiner IP. Acute gastric volvulus: case report and review of the literature. CJEM 1999;1:200–3. [5] Coulier B, Broze B. Gastric volvulus through a Morgagni hernia: multidetector computed tomography diagnosis. Emerg Radiol 2008;15:197–201. [6] Sokol AB, Morgenstern L. Gastric volvulus complicating paraesophageal hiatal hernia. Calif Med 1972;117:66–9. [7] Menuck L. Plain film findings of gastric volvulus herniating into the chest. AJR 1976;126:1169–74. [8] Seaman WB, Fleming RJ. Intramural gastric emphysema. Am J Roentgenol Radium Ther Nucl Med 1967;101:431–6. [9] Channer LT, Squires GT, Price PD. Laparoscopic repair of gastric volvulus. JSLS 2000;4:225–30. [10] Teague WJ, Ackroyd R, Watson DI, Devitt PG. Changing patterns in the management of gastric volvulus over 14 years. Br J Surg 2000;87:358–61.
