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A RARE CASE OF ORGANOAXIAL VOLVULUS IN A PATIENT PRESENTING WITH ALTERED MENTAL STATUS
Jonathan Ghobrial
*1, Mirella Youssef
2, Michael Farrell
11Allegheny Health Network Graduate Medical Education, Pittsburgh, PA; 2The Ohio State University College of Medicine, Columbus, OH
Introduction
Intrathoracic organoaxial volvulus is a rare presentation. Typical symptoms include dysphagia, vomiting, and epigastric pain. Usual treatment involves emergent surgery. It is even rarer for it to present incidentally on imaging. We present a case of an 89 year old patient who presented with stroke like symptoms and was incidentally found to have an organoaxial gastric volvulus.
Case description
We present a case of an 89-year-old female with a history of hypertension and dementia who presented to the emergency room with facial droop and inability to speak. She reportedly did not have a bowel movement for 2 weeks leading up to presentation. Patient takes risperidone and memantine for her dementia.
Patient was hemodynamically stable. CT of the abdomen showed a large paraoesophageal hiatal hernia that contained nearly the entire stomach with organo-axial volvulus (no gastric obstruction), large amount of stool dilation of the rectum, and mild bladder wall thickening. CT angiogram of the head and neck showed narrowing at the origins of both vertebral arteries. CT of the head unremarkable.
MRI and CT imaging of the brain showed no evidence of ischemia and/or hemorrhage, making TIA likely etiology of her presentation. Patient's facial droop improved without intervention. Patient began having regular bowel movement with a bowel regimen. Urinary retention subsequently improved. CT surgery was consulted given CT abdomen findings. No surgical intervention was warranted given patient did not have clinical signs of obstruction.
Discussion
Intrathoracic gastric volvulus is a rare and potentially fatal condition often misdiagnosed as other gastrointestinal disorders like GERD or gastritis due to overlapping symptoms such as dysphagia, vomiting, and epigastric pain. It can occur when the stomach partially or fully herniates into the thoracic cavity, often due to a right-sided diaphragmatic hernia. Gastric volvulus is classified into primary (ligament laxity) or secondary (diaphragmatic defects or adhesions) types, with its hallmark clinical presentation being Borchardt’s triad: severe epigastric pain, intractable retching, and inability to pass a nasogastric tube. Strangulation, obstruction, or upper GI bleeding are severe complications requiring prompt surgical intervention. CT imaging is critical for diagnosis, and treatment options include laparoscopic gastropexy or endoscopic de-rotation. This case highlights the need for a high index of suspicion and timely diagnosis to avoid life-threatening outcomes.
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