An unresponsive 83-year-old white male presented with respiratory failure, hypotension, and marked abdominal distention. There was no history of vomiting. Abdominal exam revealed marked distention and hypoactive bowel sounds. Initial labs included a Hbg of 13.2 gm/dl, WBC 15.7/cmmm, platelets 149,000/cmm, pH 7.11, HCO3 10 mmol/L and lactic acid 10.0 mmol/L. Attempts to place a nasogastric tube were unsuccessful. An x-ray showed massive dilation of the stomach and multiple loops of small bowel. The nasogastric tube was coiled within the esophagus.

An emergent upper GI endoscopy revealed a dilated esophagus with a large amount of residual fluid. Near the GE junction, a complete obstruction due to esophageal torsion was noted. The endoscope was unable to pass the point of torsion.

An exploratory laparotomy revealed an ischemic, massively dilated stomach, twisted around its organoaxial axis and incarcerated jejunum through a right inguinal hernia. Six liters of feculent gastric fluid were aspirated through a gastrotomy, and the stomach was untwisted. The incarcerated jejunum was reduced, the hernia repaired, and a gastrostomy tube was placed. Postoperatively, the patient rapidly deteriorated and died 12 hours later due to multi-system organ failure and profound metabolic acidosis.