Author: Chris Callow, Riad Hosein / Editor: Nick Tilbury / Codes: GP1, GP9, SLO1, SLO2, SuC16, SuP1, SuP7 / Published: 23/01/2024

An 82-year-old lady is brought by ambulance from her care home after vomiting twice. Carers described the vomit as ‘coffee ground’ in appearance. The paramedics pre-alert her as she has an episode of atrial fibrillation with fast ventricular response of around 170bpm, but both this and the vomiting have stopped by the time you assess the patient.

She is drowsy and confused and is unable to provide much history. She has recently moved to the area and there is no previous history available but her son tells you she has dementia and has had problems with her swallowing for years.

Her observations are:

  • SpO2 98% on air
  • Respiratory rate 28bpm
  • Blood pressure 138/60mmHg
  • Heart rate 80bpm

On examination she has a low-grade fever and is intermittently retching. She opens eyes to voice and mumbles a few words incoherent words. The abdomen appears soft but you note she grimaces on palpation. The ECG shows atrial fibrillation without ischaemic changes and the blood gas shows a normal pH but a lactate of 4.

You request a CT scan of the abdomen, which shows a gastric volvulus with evidence of early ischaemic changes. It takes four attempts to pass a nasogastric (NG) tube which eventually drains a large volume of dark coloured watery gastric effluent, and the patient is admitted under surgery, who advise conservative management.