Virginia Research Day 2022

Medical Resident Research Case Reports

08 Peg Tube Induced Gastric Volvulus

Janice Chuang, DO; Ryan O’Connell, DO; and Tara Mancl, MD Corresponding author: Janice.chuang@lpnt.net

SOVAH Health Internal Medicine Residency Program

Context: Gastric volvulus is a rare condition resulting from the rotation of the stomach or part of the stomach by more than 180˚, creating a closed-loop obstruction. Gastric volvulus is a life-threatening condition, with high morbidity and mortality, secondary to gastric ischemia, perforation, and necrosis. Borchardt reported gastric volvulus triad as acute stomach distention or pain, inability to pass nasogastric tube, and non-productive attempts at vomiting. Case Report: A 26-year-old female that presented to the ED with complaints of acute nausea and vomiting, abdominal pain. Medical History: Cerebral palsy, non-verbal and PEG tube dependent at baseline, severe developmental disability, Ogilvie syndrome s/p decompression in 2017 and 2018, and seizure disorder Family History: Maternal Grandmother with hx of “GI issues”, family was unclear. Social History: Non-verbal and completely dependent for all basic ADL’s. Pertinent Review of Systems: Unable to obtain.

Pertinent Physical Exam: BP 145/95. HR 125. RR 20. T 97.5. 100% on RA. Distended and tight abdomen, no bowel sounds. Pertinent Labs: Lactic acid of 4.8, mild leukocytosis of 13.9, and lipase of 949. Imaging: CT abdomen and pelvis with contrast showed severely dilated air and fluid- filled viscous thought to represent the stomach. Patulous fluid-filled esophagus. Diagnosis: Intractable Nausea and Vomiting secondary to abdominal distention in the setting of recurrent Ogilvie Syndrome. Treatment: Patient was initiated on conservative measures with NG tube, fluids and PRN pain scale. General surgery and GI were consulted for recurrent Ogilvie and the need for EGD/colonic decompression. GI recommended contrast-enhanced abdominal x-ray secondary to no NG tube output despite multiple attempts at repositioning the tube. This study revealed no evidence of contrast drainage into the stomach, concerning for gastric volvulus. The patient was taken for emergency surgical intervention and found to have acute gastric volvulus wrapped 2-3 times around the PEG tube. The patient underwent total gastrectomy

with Roux-en-Y esophagojejunostomy, appendectomy and feeding jejunostomy placement. The patient was then transferred to the ICU. Post-op discussion with family revealed that the patient's PEG tube had been dislodged multiple times recently and re- inserted in the ER. The patient had a prolonged stay in the ICU and eventually was discharged to a group home after patient was tolerating feeds through J-tube. Comments: While PEG tubes are broadly accepted as safe for a more permanent enteral access there are many complications and risk with the procedure. Common complications of PEG tube include leakage, tube occlusion or dislodgement. There have also been increased concerns and reports about small bowel and gastric volvulus after laparoscopic procedures. This is thought to be due to bowel mobilization and manipulation, set inclination of the operating table, and stasis and pneumoperitoneum. Most cases are typically reported after a recent laparoscopic procedure. In our situation, we suspect that the replacement of the PEG tube was the inciting factor that led to the gastric volvulus.

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