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Intermittent Gastric Volvulus Mimicking Acute Coronary Syndrome

Chest radiograph with epigastric air-fluid level. The stomach has been displaced superiorly into the chest.

Chest radiograph with epigastric air-fluid level. The stomach has been displaced superiorly into the chest.

Intermittent gastric volvulus plagued a 61-year-old white woman with chest pain for months before it was observed on esophagogastroduodenoscopy (EGD). She presented to the Emergency Department with complaints of progressively worsening localized, burning, left-sided and substernal chest pain that was identical to her previous myocardial infarction. Her chest pain was associated with nausea, vomiting, and shortness of breath. She experienced no relief with the administration of sublingual nitroglycerin and aspirin. Due to her prior history of coronary artery disease with left anterior descending artery stent placement, acute coronary syndrome was highest on her differential diagnosis list during her visits to the hospital. In fact, the concern was so great that she underwent a nuclear medicine stress test, followed by a left heart catheterization 2 weeks prior to this hospitalization in another state during an acute episode of chest pain. During that hospitalization, the stress test showed no evidence of inducible myocardial ischemia and the left heart catheterization showed only mild to moderate stenosis of the left anterior descending artery with a patent stent. Further confounding her diagnosis was the lack of hematemesis prior to her admission, prior history of gastrointestinal bleed, or use of high-risk medications such as nonsteroidal anti-inflammatory drugs.

Her past medical history was significant for coronary artery disease with left anterior descending artery stent placement, chronic kidney disease stage 3, hiatal hernia with gastroesophageal reflux disease, and depression. Her surgical history consisted of her prior angioplasty, a vaginal hysterectomy, and tonsillectomy. She had a family history of breast cancer in her maternal grandmother and paternal grandfather and was a life-long nonsmoker who consumed alcohol only on special occasions.

Assessment

Upon admission, her vital signs were entirely within normal limits and she appeared to be resting comfortably with no evidence of distress. Apart from vague epigastric tenderness, she exhibited no abnormalities on physical examination. Her complete blood count was within normal limits and her comprehensive metabolic profile was unremarkable apart from her creatinine of 1.38 mg/dL, which was near her baseline. She had a lipase of 59 U/L. Her D-dimer and troponin I were both unremarkable, with electrocardiogram showing normal sinus rhythm without evidence of ischemia. She experienced an episode of emesis at this time that was brown and tested positive for occult blood. Subsequent stool for occult blood was negative. Her chest radiograph showed a large hiatal hernia, an epigastric air-fluid level (Figures 1 and 2), and no evidence of acute cardiopulmonary disease.

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-Jaymon B. Patel, MD, Divya Akshintala, MD, Preeti Patel, MD, Vamsi K. Emani, MD, Nikhil Kalva, MD, Imran Balouch, MD

This article originally appeared in the February 2017 issue of The American Journal of Medicine.

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