Answer:
We present a case of paraesophageal hernia complicated with organoaxial volvulus
A 75 year old male with medical history significant for Atrial fibrillation on Warfarin, and longstanding paraesophageal hernia presented with progressive worsening abdominal pain associated with coffee ground emesis of one week duration. Physical exam was remarkable for epigastric tenderness without guarding or rigidity. Laboratory workup revealed Hemoglobin 13.7, PT/INR 72/9.51. Emergent computed tomography angiography demonstrated organoaxial volvulus with the entire stomach in the posterior mediastinum and small duodenal perforation (Figure 2). Gastric decompression with Naso-gastric tube yielded coffee ground fluid. A significant drop in hemoglobin to 7.7 was noted. His PT/INR was reversed with vitamin K and Fresh frozen plasma along with packed Red Blood cell transfusion. Repeat computed tomography illustrated reduction in stomach distention. Esophagogastroduodenoscopy (EGD) revealed a tortuous esophagus with multiple large ulcerations in the body of the stomach and esophagus (Cameron lesions) (Figure 3); with no active bleeding. Patient later underwent laparoscopic transabdominal repair as definitive treatment.