EVENTRATION OF DIAPHRAGM COMPLICATED BY GASTRIC VOLVULUS IN ELDERLY FEMALE: A CASE REPORT

We report a 64 year old female who presented with epigastric pain and intractable vomiting not respond to treatment and we were not able to pass nasogastric tube. Chest x -ray shows eventration of left sided hemi diaphragm, upper gastro intestinal contrast study conform the diagnosis of gastric volvulus. Plication of left hemidiaphragm with anterior gastropexy was performed through an abdominal approach. Postoperatively the patient's symptoms improved. Acute gastric volvulus carries a mortality rate of 42-56%, secondary to gastric ischemia, perforation or necrosis. 1 Emergency physicians should have suspicion about gastric volvulus when treating patients with abdominal pain and persistent vomiting. The patient should go for surgical consultation as early INTRODUCTION: In diaphragmatic eventration, permanent elevation of an immobile hemidiaphragm occurs in which peripheral muscular attachment is normal with no interruption in peritoneal or pleural layers. It usually remains asymptomatic in early life and presents later with respiratory and occasionally gastrointestinal complications. This may lead to displacement of abdominal organs, especially the stomach. Gastric volvulus is an uncommon complication of eventration of diphragm.2 There are two types of gastric volvulus: organoaxial and mesenteroaxial. The most common type is organoaxial, in which the stomach rotates along the longitudinal axis and is associated with paraesophageal hernias. The mesenteroaxial type, in which the stomach rotates between the lesser and greater curvatures, is believed to be idiopathic, causing chronic symptoms. 3 The presence of persistent vomiting and epigastric pain despite initial antiemetic treatment should trigger one to think of gastric volvulus, despite the patient appearing very stable and healthy. Diagnosis of gastric volvulus, which can have significant morbidity and mortality can be easily missed. Early radiological imaging with x-ray or computed tomography (CT) can facilitate the management of the patient. Eventration of diaphragm is defined as an abnormal elevation of an intact diaphragm and most often is characterized by a developmental abnormality of the diaphragm musculature. 4 It usually remains asymptomatic in early life and presents later with respiratory and occasionally gastrointestinal complications. The abnormally wide diaphragmatic space provides the potential for abnormal rotation of stomach around itself. This abnormal rotation is known as gastric volvulus. It is of two varieties. One is organoaxial (more common) and other is mesentero-axial. We present a case of 60 year old female with eventration of left hemidiaphragm with chronic intermittent organo-axial gastric volvulus.