An Unusual Cause of Vomiting in the Elderly

An 82-year-old man presented to the author's hospital with vomiting. Although vital signs were normal, the patient's abdomen was tympanic and distended with tenderness. Abdominal radiography showed massive gastric dilatation (Fig. 1A), and computed tomography (CT) revealed displacement of the antrum above the gastro-esophageal junction (Fig. 1B, C) accompanied by no splenic or diaphragmatic disorders. Thus, primary mesentero-axial gastric volvulus (GV) was diagnosed by the abovementioned findings.

FIG. 1
(A) Abdominal radiography showing massive gastric dilatation. (B, C) Computed tomography revealing displacement of the antrum (arrow) above the gastro-esophageal junction (arrowhead).

• Click for larger image

An emergency endoscopy confirmed torsion of the stomach without mucosal ischemia (Fig. 2A). The endoscope was successfully passed through the volvulus. Endoscopic reduction was performed by advancing the endoscope into the third portion of the duodenum and then pulling back the endoscope while twisting to the right under X-ray guidance, which is known as the alpha-loop maneuver (Fig. 2B, C).1 The patient could take orally soon after successful reduction.

FIG. 2
(A) Endoscopy confirming torsion of the stomach without mucosal ischemia. (B, C) Endoscopic reduction under X-ray guidance.

• Click for larger image

GV, which is characterized by abnormal rotation of the stomach, is classified based on the axis of torsion: organo-axial type (long axis connecting the gastro-esophageal junction to the pylorus), mesentero-axial type (short axis bisecting the lesser and greater curvature), and combined type.2 Organo-axial GV is the most common, and mesentero-axial GV is less common.2 Furthermore, mesenteroaxial GV is not usually associated with diaphragmatic anomalies,2 and primary GV is due to the absence or laxity of the gastrosplenic and gastrocolic ligaments.3

GV is a rare disease with an unknown incidence. However, GV can follow a life-threatening clinical course due to ischemia of the gastric wall, and prompt diagnosis and treatment are necessary. Although CT is useful to demonstrate abnormal position and torsion of the stomach, it is difficult to determine the degree of mucosal ischemia.3 Therefore, early endoscopy is recommended for evaluating gastric mucosal injury. In addition, sequential endoscopic reduction is a less-invasive and effective treatment.

Especially in elderly patients, no surgical procedures may be tolerated, even though performed laparoscopically. In such cases, if the gastric volvulus recurs, endoscopic fixation including endoscopic gastropexy and gastrostomy should be considered.3