A 62-year-old woman presents to her family doctor with intermittent heartburn and early satiety with epigastric discomfort immediately following meals. She had no previous related surgery. An upper GI series (UGIS) was performed.
The abnormality on the adjacent UGIS image most likely represents:
a) Ménétriers disease (hypertrophic gastropathy)
b) large calcified right lower lobe lung mass
c) gastric lymphoma
d) small bowel malrotation
e) paraesophageal hernia with gastric volvulus
Theres barium opacification of the distal esophagus and stomach, extending through into the proximal duodenum. Most of the stomach is actually in the lower thoracic cavity, following complete 180° rotation on its long axis through a large hiatus at the gastroesophageal (GE) junction. The barium has passed back through the pylorus region into the duodenum, in its normal position in the abdomen.
The correct answer is (e): paraesophageal hernia with gastric volvulus.
Gastric volvulus is defined as an abnormal degree of rotation of one part of the stomach around another due to a congenital absence or laxity of intraperitoneal visceral ligaments. The abnormality typically involves rotation of all or part of the stomach by more than 180º, which may lead to a closed-loop obstruction and possible strangulation. There is usually an associated hiatus in the diaphragm and as the stomach herniates into the chest beside the distal esophagus (paraesophageal), it also rotates. Symptoms result from food and air distending the herniated gastric segment and range from mild ab-dominal pain and vomiting, when no obstruction is present, to severe pain, retching and possible sepsis when there is complete obstruction and ischemia. The mortality rate for acute gastric volvulus (with ischemia leading to gastric perforation) is reportedly 42-56%. The mortality rate for chronic gastric volvulus is 10-13%.
The treatment of a symptomatic patient with an intrathoracic stomach is usually surgery. If ob-struction occurs, emergent surgery is indicated. Because of the high morbidity and mortality rates that accompany complications, some surgeons advocate elective surgery for asymptomatic patients if they are good operative candidates. The results of elective repair of paraesophageal gastric volvulus are good, with low morbidity and mortality rates.
The classic clinical triad of gastric volvulus consists of severe epigastric pain, retching without vomiting and inability to pass a nasogastric tube. The definitive imaging study is the upper GI barium study.
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