Presentation
Severe epigastric pain and vomiting.
Patient Data
NGT tip is projected in the gastric fundus however the tube deviates to the left in the distal esophagus, displaced by a large air and gas-filled structure containing air-fluid levels which could represent a large gastric hiatus hernia. Given the symptoms, this is concerning for a gastric volvulus, and further immediate assessment with CT is advised.
Minor atelectasis in the left lung base. No pleural fluid or pneumothorax. No free subdiaphragmatic gas. Cardiac size is normal.
Large hiatus hernia in the posterior mediastinum containing most of the stomach. The gastro-esophageal junction and duodenum are in the correct position. The NGT is displaced to the left within the esophagus by the large hiatus hernia and the tip is in the proximal stomach (fundus) below the diaphragm.
Minor dependent change within the lungs adjacent to the large hernia. Minor increase in interstitial markings in the lower bases. The heart is of normal size. No pericardial or pleural effusion. There are a few small lymph nodes within the mediastinum which are within normal limits.
No free fluid or free air in the upper abdomen.
IMPRESSION
Large haitus hernia and possible meso-axial gastric volvulus. No evidence of perforation.
Case Discussion
The patient was a tourist and had a longstanding known hiatus hernia which had been enlarging over the last year. No prior imaging was available for review at the time of his admission. He was awaiting an elective reduction and fundoplication procedure upon returning to his home. The symptoms resolved with conservative management and the patient not clinically suspected of gastric volvulus. He returned home to have his surgery.