A 90 yo male admitted to the hospital 4 days ago begins having nausea and vomiting. Emesis is dark brown in color and continues despite anti-emetics. On exam, his abdomen is soft, mildy distended, and nontender. You obtain a stat portable abdominal x-ray. What's the diagnosis?  (scroll down for answer) 

Answer: Gastric volvulus

• Volvulus: twisting of intestine around its mesenteric attachment causing a bowel obstruction and potential ischemia
• Most common form is sigmoid volvulus (elderly patients, history of constipation, anticholingeric meds) 
• Associated with "coffee bean sign" on x-ray
• Cecal volvulus (seen in younger patients, pregnancy, marathon runners)
• Gastric volvulus is a rare form in which the stomatch twists 180 degrees
• Surgical emergency
• Borchadt's Triad: vomiting + epigastric pain + inability to pass NG tube
• Risk factors: pediatric patients with congential diaphragmatic defects, elderly patients, gastric tumors, diaphragmatic injury, hiatal hernia, L lung resection, pleural adhesions
• Definitive diagnosis: barium upper GI series vs CT scan

References:

Price TG, Orthober RJ. Price T.G., Orthober R.J. Price, Timothy G., and Raymond J. Orthober.Bowel Obstruction. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. Tintinalli J.E., Stapczynski J, Ma O, Yealy D.M., Meckler G.D., Cline D.M. Eds. Judith E. Tintinalli, et al.eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016.

Kiyani A, Khosla M, Anufreichik V, Chuang K-Y. “A Large Hiatal Hernia”: Atypical Presentation of Gastric Volvulus. Clinical Practice and Cases in Emergency Medicine. 2017;1(3):187-189. 

Jabbour G, Afifi I, Ellabib M, El-Menyar A, Al-Thani H. Spontaneous Acute Mesenteroaxial Gastric Volvulus Diagnosed by Computed Tomography Scan in a Young Man. The American Journal of Case Reports. 2016;17:283-288.