eMedicine Specialties > General Surgery > Abdomen

Gastric Volvulus

Author: Mohamed Akoad, MD, Liver Transplant Surgeon, Division of Hepatobiliary and Liver Transplantation, Department of Surgery, Veterans Administration Pittsburgh Healthcare System
Coauthor(s): Richard W Golub, MD, FACS, Consulting Surgeon, Sarasota Memorial Hospital and Doctors Hospital; Consulting Surgeon, Intercoastal Medical Group
Contributor Information and Disclosures

Updated: Aug 15, 2006

Introduction

Gastric volvulus is defined as an abnormal rotation of the stomach of more than 180°, creating a closed loop obstruction that can result in incarceration and strangulation.

History of the Procedure

Berti first described gastric volvulus in 1866; to date, it remains a rare clinical entity. Berg performed the first successful operation on a patient with gastric volvulus in 1896. Borchardt described the classic triad of severe epigastric pain, retching without vomiting, and inability to pass a nasogastric tube in 1904.

Problem

According to the axis around which the stomach rotates, gastric volvulus is classified as follows:

• Organoaxial
  • The stomach rotates around an axis that connects the gastroesophageal junction and the pylorus. The antrum rotates in opposite direction to the fundus of the stomach.
  • This is the most common type in both children and adults and is usually associated with diaphragmatic defects. Strangulation and necrosis commonly occur with this type and have been reported in 5-28% of cases.
• Mesentericoaxial
  • The axis bisects both the lesser and greater curvatures. The antrum rotates anteriorly and superiorly so that the posterior surface of the stomach lies anteriorly. The rotation is usually incomplete and occurs intermittently. Vascular compromise is uncommon.
  • Patients with this type usually present without diaphragmatic defects and usually have chronic symptoms.
• Combined
  • This is a rare form in which the stomach twists both mesentericoaxially and organoaxially.
  • This form is usually observed in patients with chronic volvulus.

Frequency

Because many cases of chronic volvulus are not diagnosed, the incidence and prevalence of gastric volvulus is unknown. Ten to 20% of cases occur in children, usually before age 1 year, but cases have been reported in children up to age 10 years. Gastric volvulus in children is often secondary to congenital diaphragmatic defects. The condition is uncommon in adults younger than 50 years. Males and females are equally affected.

Etiology

According to etiology, gastric volvulus can be classified as either type 1 (idiopathic) or type 2 (congenital or acquired).

• Type 1
  • This type comprises two thirds of cases and is presumably due to abnormal laxity of the gastrosplenic, gastroduodenal, gastrophrenic, and gastrohepatic ligaments. This allows approximation of the cardia and pylorus when the stomach is full, predisposing to volvulus.
  • This type is more common in adults but has been reported in children.
• Type 2
  • This type is found in one third of patients and is usually associated with congenital or acquired abnormalities that result in abnormal mobility of the stomach.
  • Miller and colleagues have reviewed the anatomic defects associated with this type of gastric volvulus, as presented in Table 1.
  • Table 1. Anatomic Defects Associated with Gastric Volvulus

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    Table

    Congenital defects	Diaphragmatic defects - 43%
    	Gastric ligaments - 32%
    	Abnormal attachments, adhesions, or bands - 9%
    	Asplenism - 5%
    	Small and large bowel malformations - 4%
    	Pyloric stenosis - 2%
    	Colonic distension - 1%
    	Rectal atresia - 1%
    Complicating gastroesophageal surgery	...
    Neuromuscular disorders	Poliomyelitis

    Congenital defects	Diaphragmatic defects - 43%
    	Gastric ligaments - 32%
    	Abnormal attachments, adhesions, or bands - 9%
    	Asplenism - 5%
    	Small and large bowel malformations - 4%
    	Pyloric stenosis - 2%
    	Colonic distension - 1%
    	Rectal atresia - 1%
    Complicating gastroesophageal surgery	...
    Neuromuscular disorders	Poliomyelitis

  • The most common cause of gastric volvulus in adults is diaphragmatic defects. In cases of paraesophageal hernias, the gastroesophageal junction remains in the abdomen while the stomach ascends adjacent to the esophagus, resulting in an upside-down stomach. Gastric volvulus is the most common complication of paraesophageal hernias. It has also been reported to complicate gastroesophageal surgery, neuromuscular disorders, and intra-abdominal tumors. Rarely, gastric volvulus may be a complication of liver transplant and may be related to ligation of the hepatogastric ligament during the hepatectomy. Table 2 summarizes the causes of secondary gastric volvulus in adults.
  • Table 2. Causes of Secondary Gastric Volvulus in Adults

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    Table

    Diaphragmatic Defects	Gastroesophageal surgery	Neuromuscular Disorder	Increased Intra-abdominal Pressure	Conditions Leading to Diaphragmatic Elevation
    Hiatus hernia Posttraumatic	Nissen fundoplication Total esophagectomyHighly selective vagotomyCoronary artery bypass graft	Motor neuron disease PoliomyelitisMyotonic dystrophy	Abdominal tumors	Phrenic nerve palsy Left lung resectionIntrapleural adhesions

    Diaphragmatic Defects	Gastroesophageal surgery	Neuromuscular Disorder	Increased Intra-abdominal Pressure	Conditions Leading to Diaphragmatic Elevation
    Hiatus hernia Posttraumatic	Nissen fundoplication Total esophagectomyHighly selective vagotomyCoronary artery bypass graft	Motor neuron disease PoliomyelitisMyotonic dystrophy	Abdominal tumors	Phrenic nerve palsy Left lung resectionIntrapleural adhesions

Presentation

Gastric volvulus can manifest as an acute abdominal emergency or as a chronic intermittent problem. The presenting symptoms depend on the degree of twisting and the rapidity of onset.

• Acute gastric volvulus
  • Intra-abdominal gastric volvulus most commonly manifests as the sudden onset of severe epigastric or left upper quadrant pain.
  • Intrathoracic gastric volvulus manifests as sharp chest pain radiating to the left side of the neck, shoulder, arms, and back.
  • It is often associated with cardiopulmonary compromise from gastric distension and may mimic an acute myocardial infarction.
  • Progressive distension and nonproductive retching follow the pain. Patients may have upper abdominal distension and tenderness if the stomach remains intra-abdominal; however, if intrathoracic, there may be minimal abdominal findings.
  • Occasionally, some patients present with hematemesis secondary to mucosal ischemia and sloughing. This can rapidly progress to hypovolemic shock from loss of blood and fluids.
  • The Borchardt triad (pain, retching, and inability to pass a nasogastric tube) is diagnostic of acute volvulus and reportedly occurs in 70% of cases.
• Chronic gastric volvulus
  • Patients typically present with intermittent epigastric pain and abdominal fullness following meals.
  • Patients may report early satiety, dyspnea, and chest discomfort. Dysphagia may occur if the gastroesophageal junction is distorted.
  • Because of the nonspecific nature of the symptoms, however, patients are often investigated for other common disease entities such as cholelithiasis and peptic ulcer disease.
  • Upper GI series can be diagnostic during an acute attack.

• Search for CME/CE on This Topic »

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