since borchardt discovered gastric volvulus in 1904 , there have been multiple cases of acute volvulus and its management described [ 13 ] . however , there have been no cases of acute on chronic volvulus reported in the literature . over the last 20 years , the incidence and prevalence of chronic volvuli are unknown due to many going undiagnosed and managed as gastro - oesophageal reflux [ 35 ] , which as this case emphasizes can be a life - threatening error . paraoesophageal hernias are the commonest cause and the peak incidence occurs during the fifth decade . our patient was significantly older than this and found to have a chronic volvulus that had passed through the diaphragmatic hiatus . the only symptom that may have indicated the presence of a chronic volvulus was the existence of a history of hiccups . a 95-year - old caucasian woman presented with worsening dysphagia , epigastric pain , retching without vomiting and hiccups over 5 months . fibreoptic nasoendoscopy revealed pooling of saliva in the piriform fossa and a diagnosis of pharyngeal pouch was initially made . barium swallow was abandoned due to aspiration by the patient ( fig .  1 ) . figure  1:sequence of barium swallow examinations revealing upper oesophageal tightening and aspiration . sequence of barium swallow examinations revealing upper oesophageal tightening and aspiration . the patient was referred to ent for endoscopic insertion of a nasogastric ( ng ) tube as the initial attempt failed . chest x - ray revealed the ng tube tip in the distal oesophagus ( fig .  2 ) . figure  2:chest x - ray showing the ng tube blocked at the distal oesophagus . the typical retrocardiac gas filled viscus can not be seen . her symptoms continued to range from severe retching without vomiting with hiccups to intermittent abdominal fullness and dysphagia hence the need for ng tube insertion . a ct scan revealed that an organoaxial volvulus had transmitted through the diaphragmatic hiatus and was occupying the thoracic cavity . the decision was made to treat the patient conservatively due to the patient 's multiple comorbidities and life expectancy . figure  3:ct thorax sagittal and coronal views revealed an organoaxial volvulus with the stomach occupying the thoracic cavity . ct thorax sagittal and coronal views revealed an organoaxial volvulus with the stomach occupying the thoracic cavity . gastric volvulus is a rare clinical entity that is defined as an abnormal rotation of the stomach of > 180 , leading to obstruction , strangulation and eventual necrosis . clinical presentation varies from incidental radiographic finding to catastrophic strangulation dependent on the degree of rotation and subsequent extent of strangulation . several classification systems exist , anatomical variations including organoaxial , mesenteroaxial or combination of them both , onset of symptoms , acute or chronic ( symptoms > 3 months ) or primary / secondary based on aetiology . organoaxial is the commonest form of acute volvulus occurring in approximately two - thirds of cases and is commonly secondary to paraoesophgeal hernias . it involves the stomach rotating around an axis that connects the gasto - oesophageal junction and the pylorus with the antrum rotating in an opposite direction to the fundus . acute volvulus results in vascular compromise leading to the classical borchardt 's triad of symptoms seen in 70% of cases , severe epigastric pain , retching without vomiting and inability to pass an ng tube . the pain and discomfort is similar to peptic ulcer disease , gastritis , cholecystitis or angina . barium swallow is considered the gold standard due to its ability to examine the degree of obstruction and rotation [ 2 , 3 , 8 ] . endoscopy has been shown to be reliable with difficulty in passing the pylorus being the principal finding . ct scanning can aid diagnosis , but should not delay time to surgery if indicated . in haemodynamically stable patient 's endoscopy can confirm a tortuous appearance of the stomach as well as confirm diagnosis via inability to reach the pylorus . definitive treatment of gastric volvulus includes reduction of the twisted stomach , percutaneous endoscopic gastrostomy or gastropexy . the treatment of acute volvulus typically involves immediate surgical repair to prevent vascular compromise . where patient 's co - morbidities prevent this , however , a recent review of conservatively managed volvuli revealed a high symptom recurrence rate ( 64% ) . none of their cohort developed acute complications over a follow - up period of 69 months . this case demonstrates the variability in presenting symptoms of acute on chronic gastric volvulus . in stable patients , patient 's co - morbidities and age should dictate surgical intervention or conservative management as transformation into acute volvulus is often life threatening .
gastric volvulus is a rare condition with two forms of presentation , either acute or chronic . since its discovery 
 , there have been no cases of acute on chronic volvulus discussed in the literature . 
 its vague presentation makes diagnosis and subsequent management difficult . 
 the diagnosis of acute gastric volvulus is made on clinical grounds via borchardt 's triad ; however , barium swallow and oesophagogastroduodenoscopy have been shown to play a role . 
 we describe a case of a 95-year - old caucasian woman who presented with worsening dysphagia , epigastric pain , retching without vomiting and hiccups of 5 months . 
 initially diagnosed as a hiatus hernia , the patient subsequently died following an acute on chronic gastric volvulus . 
 this rare , life - threatening diagnosis provides an opportunity to discuss characteristics of gastric volvulus and the difficulties in management .