Answer:
We present a case of paraesophageal hernia complicated with organoaxial
volvulus
A 75 year old male with medical history significant for Atrial
fibrillation on Warfarin, and longstanding paraesophageal hernia
presented with progressive worsening abdominal pain associated with
coffee ground emesis of one week duration. Physical exam was remarkable
for epigastric tenderness without guarding or rigidity. Laboratory
workup revealed Hemoglobin 13.7, PT/INR 72/9.51. Emergent computed
tomography angiography demonstrated organoaxial volvulus with the entire
stomach in the posterior mediastinum and small duodenal perforation
(Figure 2). Gastric decompression with Naso-gastric tube yielded coffee
ground fluid. A significant drop in hemoglobin to 7.7 was noted. His
PT/INR was reversed with vitamin K and Fresh frozen plasma along with
packed Red Blood cell transfusion. Repeat computed tomography
illustrated reduction in stomach distention. Esophagogastroduodenoscopy
(EGD) revealed a tortuous esophagus with multiple large ulcerations in
the body of the stomach and esophagus (Cameron lesions) (Figure 3); with
no active bleeding. Patient later underwent laparoscopic transabdominal
repair as definitive treatment.