P5078 - A Rare Case of Hiatal Hernia-Induced Gastric Volvulus Resulting in Post-Operative Gastroparesis in a Nonagenarian

Alexander Kaye, MD, MBA, Andrew Draheim, BS, Iryna Kozak, MD, Savanna Thor, DO, MPH
SUNY Downstate Health Sciences University, Brooklyn, NY

Introduction: Gastric volvulus (GV) is a rare and life threatening pathology that involves a >180 degree gastric rotation. One etiology of GV is a hiatal hernia (HH) for which there have been 366 documented cases. Among GV cases due to HH, only 4 prior cases have been reported in patients at least 90 years old. A very rare complication of a HH repair is gastroparesis, with only 6 prior documented cases. We describe a 92 year old man with a rare case of GV due to a HH whose course was complicated by an unusual complication of post-HH repair refractory gastroparesis.

Case Description/Methods: A 92 year old man with a history of hypertension, hyperlipidemia, chronic kidney disease, a distant history of prostate cancer and a distant history of an inguinal hernia repair presented to the ED with one day of vomiting. A CT abdomen/pelvis demonstrated a moderate HH and GV. Surgery was consulted who recommended operative management. Surgical findings were notable for a large HH, a giant crural defect and an umbilical hernia. During the surgery, the hernia sac was excised, the stomach was reduced into the peritoneal space, the crural defect was repaired, the stomach was anchored to the left crus and the anterior abdominal wall, and an umbilical hernia was repaired. An nasogastric tube (NGT) was placed immediately following surgery and left on low continuous suction. On post-op day 3, NGT feeds were attempted but then held due to vomiting. On post-op day 7, a gastric emptying study was obtained that was notable for 91% of gastric content retained at 4 hours. A treatment course of metoclopramide was initiated but discontinued after one day due to an elevated QTc. Given the persistence of the patient’s symptoms, treatment limitations due to an elevated QTc, and nutritional requirements, on post-op day 20, the patient underwent an IR placed percutaneous endoscopic gastrojejunostomy (PEG-J). Within 48 hours after PEG-J placement, the patient experienced significant symptomatic improvement and feeds were started without incident. Discharge planning was subsequently initiated. A diagnostic EGD was performed demonstrating no evidence of a gastric outlet obstruction.

Discussion: This is one of the first reported cases of both GV due to HH in a patient over 90 years old, and HH repair as the etiology of post-surgical gastroparesis. Given the several rare aspects to this case, we hope that it will add to a limited body of literature describing treatment of HH-induced GV, and post-surgical gastroparesis in nonagenarian individuals.


Disclosures:


Alexander Kaye, MD, MBA, Andrew Draheim, BS, Iryna Kozak, MD, Savanna Thor, DO, MPH. P5078 - A Rare Case of Hiatal Hernia-Induced Gastric Volvulus Resulting in Post-Operative Gastroparesis in a Nonagenarian, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.