Background

Cascade stomach is an uncommon anatomical finding, consisting of a displacement of the fundus dorsally, creating a gravity-dependent secondary stomach pocket. Exact etiologies are unknown, but organic, congenital, and extrinsic causes have been theorized. Cascade stomach causes primarily nonspecific upper GI symptoms initially diagnosed as GERD, gastritis, and gastroparesis.Our patient is a 58-year-old female with class 1 obesity who suffered with a 20-year history of progressive upper GI symptoms, including bloating, belching, and epigastric pain radiating into the chest. Symptoms worsened with eating and forward flexion. The patient developed an abdominal massage routine she would employ to improve her symptoms. An EGD report initially described a large paraoesophageal hernia with most of the stomach in the chest. However, in a follow-up UGI study, a classic cup and spill deformity was then found, consistent with the diagnosis of cascade stomach. We proceeded with a robotic sleeve gastrectomy operation and appreciated a sizable fibrous adhesive band and increased angulation at the fundus. Complete resolution of her symptoms was evident on follow-up at 2 weeks along with approximately 50-pound weight loss at the 1-year follow-up.This case highlights the importance of considering cascade stomach in the differential diagnosis for upper GI symptoms. Once more common causes, such as GERD, medication effects, ulcer, are ruled out, an upper GI study is likely the best test to diagnose cascade stomach. This case also demonstrates the potential role of sleeve gastrectomy as a curative operation for this primary anatomical abnormality in patients with comorbid obesity.