A 70-year-old woman presents with sudden severe epigastric pain, unproductive retching, and inability to pass a nasogastric tube beyond the gastroesophageal junction. Plain radiograph shows a gas-filled viscus in the left hemithorax. What is the most likely diagnosis and correct management?

• A Boerhaave syndrome managed with broad-spectrum antibiotics alone
• B Sliding hiatus hernia managed with proton pump inhibitors
• C Paraesophageal hiatus hernia with gastric volvulus requiring emergency surgery ✓
• D Pharyngoesophageal diverticulum managed with cricopharyngeal myotomy

Explanation

The Borchardt triad of severe epigastric pain, unproductive retching and inability to pass a nasogastric tube indicates acute gastric volvulus, usually complicating a type II (rolling) paraesophageal hernia. It is a surgical emergency because strangulation, gangrene and perforation follow if reduction is delayed; endoscopic detorsion is only a temporising measure in unfit patients. Sliding hernias rarely volvulise, and the absence of fever or pneumomediastinum argues against Boerhaave syndrome.

Reference: Bailey and Love's Short Practice of Surgery, 27th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.