We have presented an unusual case of a patient with intractable and positional borborygmi, nausea and early satiety due to a gastric deformity in the upright position causing an hourglass stomach. On inspiration, air was forced through the deformity, causing audible borborygmi. These sounds stopped completely on breath-holding when the patient was in the upright position or when she was lying down. The prominence of the borborygmi, combined with the patient's distress and associated symptoms, resulted in numerous investigations that aimed to find an underlying cause. A number of initial investigations, including gastroscopy, abdominal CT scan and laparoscopy, failed to identify a cause. This may have been the case as the patient would have been supine for these tests and the gastric abnormality would not have been present.
Gastric deformities may be associated with audible borborygmi. However, case reports of this are sparse. In 1944, Lawrence reported a patient, with a symptomatic paraoesophageal hernia, who had audible inspiratory borborygmi.
1 Borborygmi were synchronous with inspiration and were loudest on auscultation over the left lower chest and epigastrium. They ceased when the patient held her breath or sat up.
The main cause of an hourglass deformity is scarring of the mid-stomach from chronic peptic ulcer disease. Other rarer causes are gastric syphilis,
2 caustic ingestion,
3 tuberculosis
4 and failed anti-reflux surgery.
5 These defects, however, tend to be fixed and not reversible by changing position.
This case also poses a number of management difficulties. Although surgery was initially considered, this was felt to be potentially hazardous, given the patient's recurrent thromboemboli and long-term anticoagulation and psychological issues. In addition, because no abnormality had been seen on laparoscopy, surgery may not have been successful. As it was noted that the sounds were reduced by pressure in the left hypochondrium, a tight-fitting corset was suggested to the patient so as to apply pressure in that area. This suggestion was not effective, although there were questions about compliance with this treatment option.
It is unclear why our patient's borborygmi only began 2 years ago, given that the problem would seem to be anatomical. An interesting hypothesis is that significant weight loss due to anorexia nervosa, resulting in loss of abdominal wall and visceral fat, in her case, resulted in close apposition of the gastric wall and ribcage in the standing position. Weight gain, with increased ‘cushioning’ between the stomach and ribcage due to abdominal wall and visceral fat, might therefore alleviate the problem. Clearly this will require vigorous management of her psychological issues through counselling and support and continuing dietetic input.
This case would seem to be the first report of a positional gastric hourglass deformity causing intractable borborygmi. The cause was eventually determined, by barium-contrast study, to be due to compression of the stomach by the left anterior ribs in the upright position.
Learning points- Consider gastric anatomical abnormalities in patients with recurrent borborygmi, especially if repeated investigations fail to identify a cause.
- Borborygmi that are related to respiration are likely to be caused by diaphragmatic compression.
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