Failure to Recognize Borchardt's Triad: A Case Presentation.
The time following presentation of a rare condition is an optimal time for learning. Healthcare practitioners and unlicensed healthcare personnel may have limited knowledge and practice experience with rare conditions. Healthcare scholars should research rare conditions, illnesses, and diseases, and disseminate lessons learned to the healthcare community.
The purpose of this article is to present a surgical case that involved double gastric volvulus and resulted in a complete gastrectomy. Authors wish to educate clinical nurses and nursing students on the signs and symptoms of gastric volvulus with hopes of increasing knowledge related to the illness, improving assessment and early detection, and thereby decreasing the mortality rate (Shukla et al., 2014).
According to Sinwar (2015), gastric volvulus first was described by Berti in 1866. Gastric volvulus has two different presentations: acute or chronic. Because presenting symptoms are vague, diagnosis and treatment plan may be difficult to formulate (Senior & Hari, 2014). The severe abdominal pain of acute gastric volvulus is accompanied by a diagnostic triad known as Borchardt's triad: intractable retching, epigastric pain, and an inability to pass a nasogastric tube (Marcin, Matta, & Elsayes, 2014). The chronic disorder, which occurs more commonly, may present asymptomatically or with crampy, intermittent abdominal pain (Doherty, 2015).
Three anatomic categories of gastric volvulus have been identified: organoaxial, mesenteroaxial, and combination. Organoaxial volvulus, the most common type, is initiated by rotation around the long axis of the stomach which forms an inverted stomach. This is associated with paraesophageal hernias and diaphragmatic eventration (Senior & Hari, 2014). Symptomatic gastric volvulus associated with diaphragmatic eventration is an emergency and requires immediate surgical repair (Sinwar, 2015). Mesenteroaxial volvulus occurs when the stomach rotates along the short axis and torsion occurs (Marcin et al., 2014).
A thorough history and clinical exam must be obtained with a radiograph of the abdomen and chest as well as an upper gastrointestinal series or computerized tomography (CT) scan for prompt diagnosis to avoid catastrophic consequences (Shukla et al., 2014; Sinwar, 2015). The classic radiograph is a picture with dilated gastric bubble, absence of any distal gas shadow, air fluid level, and elevation of the left hemidiaphragm (Shukla et al., 2014). The classic triad of retching, severe and constant epigastric pain, and difficulty in passing a nasogastric tube should suggest the presence of acute gastric volvulus (Sinwar, 2015). However, according to Altintoprak and co-authors (2014), there
are no specific clinical or laboratory findings and diagnosis usually is established intraoperatively.
Presenting Signs and Symptoms
A 74-year-old female presented to the Emergency Department via ambulance. The patient complained of acute chest pain and upper abdominal pain radiating to the middle back that began several hours before admission. The intensity of the chest pain was described by the patient as 9 (0-10 scale). Abdominal pain was intermittent and began with vomiting. She reported abrupt, frequent retching with vomiting only once. The patient described experiencing these symptoms for 3 hours. The patient, a retired registered nurse, had a medical history of iron deficiency anemia, osteoporosis, vitamin D deficiency, recently diagnosed hypertension, and intermittent abdominal pain in the previous 6 months. Past surgical history included tonsillectomy, adenoidectomy, and hysterectomy. The patient did not report any alcohol or tobacco use and denied any fever, change in diet, or history of chest pain or angina.
During the examination, the patient continued frequent retching without vomiting. Vital signs were as followed: blood pressure 195/98 mm Hg, radial pulse 98 beats per minute, oral temperature 98.6o F, respirations 22 breaths per minute, and oxygen saturation 97% by pulse oximetry. The patient had mild tenderness to the upper abdominal quadrants and epigastric area. An xray showed a large hiatal hernia and an ultrasound indicated cholelithiasis. The Emergency Department physician diagnosed cholelithiasis, referred the patient to a surgeon, and wrote orders to discharge the patient home. Before being discharged, however, the patient had difficulty swallowing oral medications and continued to retch. Due to the inability to take oral medications, frequent retching, and persistent severe pain, the patient was admitted to the hospital and scheduled for esophagogastroduodenoscopy (EGD) the following day.
The patient continued to exhibit these symptoms throughout the evening before the EGD. The EGD demonstrated a black discoloration of the stomach, which the surgeon attributed to long-term use of iron supplementation. While the patient was still in the endoscopy suite, the surgeon ordered a CT scan. The patient was restless after the EGD with low blood pressure and a distended abdomen. Despite the change in the patient's condition, she was transferred back to the medical-surgical unit. Restlessness increased and the patient demonstrated a distended abdomen and obvious central cyanosis; she complained of difficulty breathing. Her blood pressure was 90/60 mm Hg. Although the patient was in obvious distress, the registered nurse caring for the patient attributed the symptoms to nervousness and anxiety. A family member at bedside, who was a family nurse practitioner, urged the healthcare team to reevaluate the patient due to the change in severity of symptoms. The patient was re-evaluated and transferred immediately to the operating room for exploratory laparotomy. She was resuscitated aggressively several times during the transport and surgery. The patient was diagnosed with gastric ischemia with necrosis related to a double gastric volvulus. She underwent total gastrectomy with esophagojejunostomy and jejunostomy tube (J-tube) placement.
Management and Outcome
In this case, many members of the healthcare team failed to recognize signs and symptoms of the Borchardt's triad. This failure resulted in the patient undergoing total gastrectomy with a 10-day stay in an intensive care unit (ICU). The patient received intravenous fluids, antibiotics, and vasopressors for the majority of the ICU stay. The patient's condition remained critical due to development of atrial fibrillation and bilateral pleural effusion. After improvement, the patient was extubated at day 11 and transferred to a medical-surgical unit within the hospital. The patient spent another 11 days in the hospital, where she received physical and occupational therapy as well as feedings via J-tube. On day 22, the patient was discharged to a nearby rehabilitation facility. At the time of discharge, the patient was able to ambulate with a walker and take small sips of fluids. The patient spent 3 weeks in this facility before being discharged home. She was able to tolerate soft solids at the time of discharge, but continued to have tube feeding supplements. The patient continues to take tube feedings every 12 hours but now is eating a regular diet throughout the day. The authors were unable to find another case discussion of a patient surviving a double gastric volvulus.
Gastric volvulus is a rare occurrence, but all healthcare personnel must be aware of its existence and able to recognize presenting symptoms quickly (Senior & Hari, 2014). The incidence and prevalence are unknown but the mortality rate is as high as 30%-50%, possibly higher with delayed treatment. The patient's prognosis depends on prompt treatment (Shukla et al., 2014). Preventing gastric necrosis is the priority and rapid intervention is key to reducing morbidity (Shukla et al., 2014). Patients with gastric volvulus typically present with abdominal distention, severe upper abdominal pain, and intractable retching with a lack of, or very little, emesis (Marcin et al., 2014).
In this case study, the subject experienced these symptoms over a 3-hour period before seeking medical intervention, and symptoms continued throughout the evening of admission. According to Marcin and colleagues (2014), radiographic evidence of volvulus would show a dilated gastric bubble, absence of a gas shadow, and elevation of the left diaphragm. The subject in this case study did not demonstrate these traits. Radiographic imaging demonstrated a large hiatal hernia, but no further evidence of gastric volvulus. Due to the absence of these cardinal radiographic signs, even with other classic symptoms present, the patient was admitted to the hospital for EGD the next morning. According to Doherty (2015), it is not uncommon for a patient to present asymptomatically; however, this patient had a classic Borchardt's triad. Emergency surgery later confirmed a diagnosis of volvulus with extensive necrosis. Because early diagnosis is essential to decrease gastric ischemia and necrosis, awareness of the symptoms associated with this subject's case could have decreased complications.
Gastric volvulus is rare, making preoperative diagnosis often difficult (Altintoprak et al., 2014). Prevention of the very high morbidity and mortality due to complications of gastric volvulus requires early diagnosis, early surgical referral, and urgent surgical intervention (Sinwar, 2015). This clinical case demonstrates the need for nurses and other members of the healthcare team to be aware of related signs and symptoms so treatment may begin quickly when volvulus is suspected. [MS
Altintoprak, F, Yalkin, O., Dikicier, E., Kivilcim, T., Gunduz, Y, & Ozkan, O. (2014). A rare etiology of acute abdominal syndrome in adults: Gastric volvulus--case series. International Journal of Surgery Case Reports, 5(10), 731-734. doi:10. 1016/j .ijscr.2014.08.024
Berti, A. (1866). Singolare attorcigliamento dell'esofago col duodeno sequito da rapida morte. Gazzetta Medica Italiana, 9, 139-141.
Doherty, G.M. (2015). Stomach & duodenum. In G.M. Doherty (Ed.), Current diagnosis & treatment: Surgery (14th ed.). Retrieved from http://accessmedicine.mhmedical.com/content.aspx?bookid=1202§ionid=71520281 Marcin, P, Matta, E.J., & Elsayes, K.M. (2014). Gastrointestinal imaging. In K.M. Elsayes & S.A.A. Oldham (Eds.), Introduction to diagnostic radiology. New York, NY: McGraw- Hill Education. Senior, A., & Hari, C. (2014). A rare case of acute on chronic gastric volvulus with Borchardt's triad. Journal of Surgical Case Reports, (11), 1-3. doi:10.1093/jscr/rju114
Shukla, R. Mandal, K., Maitra, S., Ray, A., Sarkar, R., Mukhopadhyay, B., & Bhattacharya, M., (2014). Gastric volvulus with partial and complete gastric necrosis. Journal of Indian Association of Pediatric Surgeons, 19(1) 49-51.
Sinwar, P.D. (2015). Gastric mesenteroaxial volvulus with partial eventration of left hemidiaphragm: A rare case report. International Journal of Surgery Case Reports, 9, 51-53. doi:10.1016/j.ijscr. 2015.02.034
Aimee Vael, DNP, RN, APRN, FNP-BC, is Associate Professor of Nursing, Columbus State University, Columbus, GA.
Kelli Whitted, DNP, FNP-BC, APRN-BC, is Assistant Professor, School of Nursing, Troy University, Troy, AL.
Elizabeth Frander, DNP, RN, APRN, FNP-BC, CNE, is Professor, Columbus State University, Columbus, GA.
LaTonya Santo, EdD, MSN, RN, is Associate Professor, Columbus State University School of Nursing, Columbus, GA.
Amanda Hawkins, MSN, RN, is Associate Professor of Nursing, Columbus State University, Columbus, GA.
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|Title Annotation:||Case Study|
|Author:||Vael, Aimee; Whitted, Kelli; Frander, Elizabeth; Santo, LaTonya; Hawkins, Amanda|
|Article Type:||Clinical report|
|Date:||May 1, 2017|
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