Gastric Volvulus Caused By Strangulated Paraesophageal Hernia In Pregnant (3rd Trimester) Lady

Khalid Ibrahim, Riffat Naqvi, Sarah Fatima, Bushra Aman

Abstract

Para esophageal hernia occurs without symptoms or present in emergency. We present a case of 27 years old pregnant(3rdtrimester) lady, referred by gynecologist after treating conservatively excessive vomiting and pain epigastrium (3 days duration) on the basis of pregnancy associated –peptic ulcer disease with no past history of heart burns with mild hydronephrosis left kidney on ultrasound, mildly raised total leukocyte count and serum amylase. She remained well for two days, and then suddenly developed hemetemsis and severe epigastric pain, difficulty in breathing and localized tenderness with hypotension and tachycardia. Upper GI endoscopy was done showing necrotic erythematous patches in fundus area and endoscope could not be negotiated beyond that point. After counseling of patient and husband regarding fetus safety, upper GI gastrograffin study was done, which showed dumbble shaped stomach with central constriction. CT scan chest and abdomen with contrast revealed half of the stomach within left chest.

Emergency laparotomy was performed which showed tight esophageal hiatus with strangulated paraesophageal hernia leading to gastric vulvulus more than 3/4th of stomach along with omentum gangrene leaving small portion of pyloric area intact and foul-smelling fluid in left chest. Total gastrectomy, closure of duodenal stump, feeding jejunostomy, exclusion of esophagus due to friable gastroesophageal junction and chest intubation were done. Patient was managed on ventilator support along with gynecological care and oesphagojejunostomy Roux-en-Y was planned later on due to condition of patient and friability of tissues. A high index of suspicion should exercised in unusual episodes of excessive vomiting in a pregnant lady in third trimester.

Key words

Strangulated paraesophageal hernia, Volvulus, Vomiting in pregnancy.