Hiatal Hernia History? Consider Gastric Volvulus

NEW ORLEANS – Think ‘chronic gastric volvulus’ when a patient with a history of hiatal hernia presents with nonspecific symptoms such as difficulty in swallowing food and uncomfortable fullness after eating.

Gastric volvulus – a torsional twisting of the stomach – is an underrecognized complication of hiatal hernia. It occurs most often in patients with a large paraesophageal hiatal hernia or with an intrathoracic stomach that has come loose from its abdominal moorings, Dr. Conor G. Loftus explained at the conference.

Acute gastric volvulus is a surgical emergency. It typically presents suddenly with severe pain in the lower chest or upper abdomen, often accompanied by persistent nonproductive retching. It’s often mistaken for an acute MI. Yet acute gastric volvulus is no less serious an event, according to Dr. Loftus, a gastroenterologist at the Mayo Clinic, Rochester, Minn.

In contrast, chronic gastric volvulus is characterized by considerably milder, nonspecific symptoms. When clinical suspicion focuses on this possible diagnosis, the best confirmatory test is a barium esophagram.

Dr. Loftus presented an illustrative case: a 70-year-old man who presents complaining of nonpainful difficulty in swallowing solid food but not liquids for the past several years. He has a history of hiatal hernia as well as long-standing gastroesophageal reflux disease controlled with once-daily proton pump inhibitor therapy. He hasn’t lost weight. A gastroenterologist performed upper endoscopy with grossly normal findings, albeit with a notation that it was somewhat difficult to pass the probe across a tortuous esophagus and stomach.

In this vignette, Dr. Loftus observed, the clinical presentation and endoscopic findings raise a red flag for chronic gastric volvulus. In particular, the reported earlier difficulty in passing the endoscope suggests a mechanical problem.

Ordering esophageal manometry would be the right choice if a dysmotility disorder were suspected; however, a recent-onset dysmotility disorder would be unusual in an aged individual and, in any case, it would typically present with both liquid and solid food dysphagia.

Endoscopic ultrasound of the gastroesophageal junction or CT scan of the chest would be the appropriate imaging study if a malignancy was suspected. But the lack of weight loss in a patient with a 3-year history of symptoms argues strongly against that possibility, he continued.

Repeating the earlier upper endoscopy, this time obtaining esophageal biopsies, would be a good move if eosinophilic esophagitis was suspected; however, this disorder is uncommon at an advanced age, Dr. Loftus noted.

He reported having no financial conflicts.

NEW ORLEANS – Think ‘chronic gastric volvulus’ when a patient with a history of hiatal hernia presents with nonspecific symptoms such as difficulty in swallowing food and uncomfortable fullness after eating.

Gastric volvulus – a torsional twisting of the stomach – is an underrecognized complication of hiatal hernia. It occurs most often in patients with a large paraesophageal hiatal hernia or with an intrathoracic stomach that has come loose from its abdominal moorings, Dr. Conor G. Loftus explained at the conference.

Acute gastric volvulus is a surgical emergency. It typically presents suddenly with severe pain in the lower chest or upper abdomen, often accompanied by persistent nonproductive retching. It’s often mistaken for an acute MI. Yet acute gastric volvulus is no less serious an event, according to Dr. Loftus, a gastroenterologist at the Mayo Clinic, Rochester, Minn.

In contrast, chronic gastric volvulus is characterized by considerably milder, nonspecific symptoms. When clinical suspicion focuses on this possible diagnosis, the best confirmatory test is a barium esophagram.

Dr. Loftus presented an illustrative case: a 70-year-old man who presents complaining of nonpainful difficulty in swallowing solid food but not liquids for the past several years. He has a history of hiatal hernia as well as long-standing gastroesophageal reflux disease controlled with once-daily proton pump inhibitor therapy. He hasn’t lost weight. A gastroenterologist performed upper endoscopy with grossly normal findings, albeit with a notation that it was somewhat difficult to pass the probe across a tortuous esophagus and stomach.

In this vignette, Dr. Loftus observed, the clinical presentation and endoscopic findings raise a red flag for chronic gastric volvulus. In particular, the reported earlier difficulty in passing the endoscope suggests a mechanical problem.

Ordering esophageal manometry would be the right choice if a dysmotility disorder were suspected; however, a recent-onset dysmotility disorder would be unusual in an aged individual and, in any case, it would typically present with both liquid and solid food dysphagia.

Endoscopic ultrasound of the gastroesophageal junction or CT scan of the chest would be the appropriate imaging study if a malignancy was suspected. But the lack of weight loss in a patient with a 3-year history of symptoms argues strongly against that possibility, he continued.

Repeating the earlier upper endoscopy, this time obtaining esophageal biopsies, would be a good move if eosinophilic esophagitis was suspected; however, this disorder is uncommon at an advanced age, Dr. Loftus noted.

He reported having no financial conflicts.

NEW ORLEANS – Think ‘chronic gastric volvulus’ when a patient with a history of hiatal hernia presents with nonspecific symptoms such as difficulty in swallowing food and uncomfortable fullness after eating.

Gastric volvulus – a torsional twisting of the stomach – is an underrecognized complication of hiatal hernia. It occurs most often in patients with a large paraesophageal hiatal hernia or with an intrathoracic stomach that has come loose from its abdominal moorings, Dr. Conor G. Loftus explained at the conference.

Acute gastric volvulus is a surgical emergency. It typically presents suddenly with severe pain in the lower chest or upper abdomen, often accompanied by persistent nonproductive retching. It’s often mistaken for an acute MI. Yet acute gastric volvulus is no less serious an event, according to Dr. Loftus, a gastroenterologist at the Mayo Clinic, Rochester, Minn.

In contrast, chronic gastric volvulus is characterized by considerably milder, nonspecific symptoms. When clinical suspicion focuses on this possible diagnosis, the best confirmatory test is a barium esophagram.

Dr. Loftus presented an illustrative case: a 70-year-old man who presents complaining of nonpainful difficulty in swallowing solid food but not liquids for the past several years. He has a history of hiatal hernia as well as long-standing gastroesophageal reflux disease controlled with once-daily proton pump inhibitor therapy. He hasn’t lost weight. A gastroenterologist performed upper endoscopy with grossly normal findings, albeit with a notation that it was somewhat difficult to pass the probe across a tortuous esophagus and stomach.

In this vignette, Dr. Loftus observed, the clinical presentation and endoscopic findings raise a red flag for chronic gastric volvulus. In particular, the reported earlier difficulty in passing the endoscope suggests a mechanical problem.

Ordering esophageal manometry would be the right choice if a dysmotility disorder were suspected; however, a recent-onset dysmotility disorder would be unusual in an aged individual and, in any case, it would typically present with both liquid and solid food dysphagia.

Endoscopic ultrasound of the gastroesophageal junction or CT scan of the chest would be the appropriate imaging study if a malignancy was suspected. But the lack of weight loss in a patient with a 3-year history of symptoms argues strongly against that possibility, he continued.

Repeating the earlier upper endoscopy, this time obtaining esophageal biopsies, would be a good move if eosinophilic esophagitis was suspected; however, this disorder is uncommon at an advanced age, Dr. Loftus noted.

He reported having no financial conflicts.