Management of acute upside-down stomach

Background: Upside-down stomach (UDS) is characterized by
herniation of the entire stomach or most gastric portions into the
posterior mediastinum. Symptoms may vary heavily as they are
related to reflux and mechanically impaired gastric emptying. UDS
is associated with a risk of incarceration and volvulus development
which both might be complicated by acute gastric outlet
obstruction, advanced ischemia, gastric bleeding and perforation.
Case presentation: A 32-year-old male presented with acute
intolerant epigastralgia and anterior chest pain associated with
acute onset of nausea and vomiting. He reported on a previous
surgical intervention due to a hiatal hernia. Chest radiography and
computer tomography showed an incarcerated UDS. After immediate
esophago-gastroscopy, urgent laparoscopic reduction, repair with a
360 degrees floppy Nissen fundoplication and insertion of a
gradually absorbable GORE (R) BIO-A (R)-mesh was performed.
Conclusion: Given the high risk of life-threatening complications
of an incarcerated UDS as ischemia, gastric perforation or severe
bleeding, emergent surgery is indicated. In stable patients with
acute presentation of large paraesophageal hernia or UDS exhibiting
acute mechanical gastric outlet obstruction, after
esophago-gastroscopy laparoscopic reduction and hernia repair
followed by an anti-reflux procedure is suggested. However, in
cases of unstable patients open repair is the surgical method of
choice. Here, we present an exceptionally challenging case of a
young patient with a giant recurrent hiatal hernia becoming
clinically manifest in an incarcerated UDS.