To the Editor: The medical mystery in the March 6 issue1 involvedan 82-year-old woman who presented with respiratory symptomsand then, 6 years later, presented with epigastric pain, nausea,and vomiting. During her first visit, an intrathoracic stomachand an asymptomatic partial gastric volvulus (Panel A, arrows)were diagnosed. The patient refused any intervention at thattime. She remained asymptomatic until she presented with theepigastric pain, nausea, and vomiting. An upper endoscopic studyshowed twisting of gastric folds, and the endoscope could notbe advanced beyond 5 cm from the gastroesophageal junction.A barium study (Panel B) and a computed tomographic scan ofthe chest and abdomen (Panel C) showed an organoaxial gastricvolvulus and an intrathoracic stomach (arrows). The patientcontinued to refuse surgical intervention, but her symptomsresolved without treatment. At a follow-up visit 12 months later,she remained free of symptoms.
Panel A shows the original chest film; 6 years later, a barium study (Panel B) and computed tomography (Panel C) were performed. See the text for explanations of the arrows.
Rangan Murali, M.D. Bashar M. Attar, M.D., Ph.D. Cook County–John H. Stroger Hospital Chicago, IL 60612 bashar_attar{at}rush.edu
Editor's note: We received 1610 responses, from 85 countries,for this medical mystery. Sixty-two percent of respondents werephysicians in practice, 21% were physicians in training, and12% were medical students. Of the respondents, 65% identifiedsome type of diaphragmatic hernia on the radiograph, which revealeda retrocardiac gastric shadow (Panel A). Specifically, 46% suggesteda hiatal hernia, and 13% proposed another type of diaphragmaticdefect such as Bochdalek's or Morgagni's hernia; 6% correctlyidentified gastric volvulus. The remaining 35% of respondentssuggested a variety of diagnoses, including aortic aneurysm,Boerhaave's syndrome, Zenker's diverticulum, thymoma, pulmonaryabscess, and achalasia.
References
Murali R, Attar BM. A medical mystery: epigastric pain. N Engl J Med 2008;358:1053-1053. [Free Full Text]
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