eMedicine Specialties > General Surgery > Abdomen

Gastric Volvulus

Author: William W Hope, MD, Assistant Professor of Surgery, University of North Carolina at Chapel Hill School of Medicine; Director of Surgical Education, Department of Surgery, New Hanover Regional Medical Center/South Eastern Area Health Education Center
Coauthor(s): Mohamed Akoad, MD, Liver Transplant Surgeon, Division of Hepatobiliary and Liver Transplantation, Department of Surgery, Veterans Administration Pittsburgh Healthcare System; Richard W Golub, MD, FACS, Consulting Surgeon, Sarasota Memorial Hospital and Doctors Hospital; Consulting Surgeon, Intercoastal Medical Group
Contributor Information and Disclosures

Updated: Jul 21, 2009

Introduction

Gastric volvulus is a rare clinical entity 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 a female autopsy patient in 1866.1 Years later, in 1896, Berg performed the first successful operation for gastric volvulus.2 The classic triad associated with gastric volvulus of severe epigastric pain, retching without vomiting, and inability to pass a nasogastric tube was described by Borchardt in 1904.3

Problem

The most frequently used classification system of gastric volvulus, proposed by Singleton,4  relates to the axis around which the stomach rotates and 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 of gastric volvulus occurring in approximately 59% of cases,5 and is usually associated with diaphragmatic defects. Strangulation and necrosis commonly occur with this type and have been reported in 5-28% of cases.6
  • Mesentericoaxial
    • The axis bisects 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. This etiology comprises approximately 29% of cases.5
    • 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 mesentericoaxially and organoaxially.
    • Combined gastric volvulus makes up the remainder of cases and is usually observed in patients with chronic volvulus.7

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,8 usually before age 1 year, but cases have been reported in children up to age 15 years.9 Gastric volvulus in children is often secondary to congenital diaphragmatic defects. The condition is uncommon in adults younger than 50 years.8 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 type 2 gastric volvulus in the pediatric population,10 as presented in Table 1.
    • Table 1. Anatomic Defects Associated with Gastric Volvulus10

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      Table
      Congenital defectsDiaphragmatic 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 disordersPoliomyelitis
      Congenital defectsDiaphragmatic 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 disordersPoliomyelitis
    • The most common causes of gastric volvulus in adults are 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.11

      Gastric volvulus after laparoscopic left adrenalectomy12 or laparoscopic adjustable gastric band placement,13 or related to eventration of the diaphragm14  or to a large-cell neuroendocrine carcinoma in the stomach,15 have been reported. 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 DefectsGastroesophageal surgeryNeuromuscular DisorderIncreased Intra-abdominal PressureConditions Leading to Diaphragmatic Elevation
      Hiatal hernia PosttraumaticNissen fundoplication Total esophagectomyHighly selective vagotomyCoronary artery bypass graftMotor neuron disease PoliomyelitisMyotonic dystrophyAbdominal tumorsPhrenic nerve palsy Left lung resectionIntrapleural adhesions
      Diaphragmatic DefectsGastroesophageal surgeryNeuromuscular DisorderIncreased Intra-abdominal PressureConditions Leading to Diaphragmatic Elevation
      Hiatal hernia PosttraumaticNissen fundoplication Total esophagectomyHighly selective vagotomyCoronary artery bypass graftMotor neuron disease PoliomyelitisMyotonic dystrophyAbdominal tumorsPhrenic 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.10
    • Carter described 3 additional findings that are suggestive of gastric volvulus including minimal abdominal findings when the stomach is in the thorax, gas-filled viscus in the lower chest or upper abdomen on chest radiograph, and obstruction at the site of the volvulus on upper GI series.6
    • Hiccups have been reported to be a subtle sign in the clinical diagnosis of gastric volvulus.16
  • 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.

Indications

In general, the treatment of an acute gastric volvulus remains emergent surgical repair. In patients who are not surgical candidates (secondary to comorbidities or an inability to tolerate anesthesia), endoscopic reduction may be attempted.

Chronic gastric volvulus may be treated nonemergently, and surgical treatment is increasingly being performed using a laparoscopic approach.

Contraindications

Contraindications for surgical treatment involve conditions or comorbidities in which the patient cannot tolerate general anesthesia. The surgeon should also use clinical judgment and make sure the patient is optimized and resuscitated prior to the operation.

Some have advocated consideration of emergent endoscopic reduction in the setting of acute gastric volvulus in patients who are high risk for surgery.17 This strategy may allow the patient to be adequately resuscitated and medically optimized prior to definitive surgical repair.

More on Gastric Volvulus

Overview: Gastric Volvulus
Workup: Gastric Volvulus
Treatment: Gastric Volvulus
Follow-up: Gastric Volvulus
References
Further Reading
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References

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Keywords

gastric volvulus, volvulus, abnormal rotation of the stomach, closed loop obstruction, incarceration, strangulation, diaphragmatic defects, paraesophageal hernias, upside-down stomach, severe epigastric pain, nonproductive retching, endoscopic reduction, percutaneous endoscopic gastrostomy, gastrectomy, anterior gastropexy

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Contributor Information and Disclosures

Author

William W Hope, MD, Assistant Professor of Surgery, University of North Carolina at Chapel Hill School of Medicine; Director of Surgical Education, Department of Surgery, New Hanover Regional Medical Center/South Eastern Area Health Education Center
William W Hope, MD is a member of the following medical societies: American College of Surgeons, North Carolina Medical Society, and Society of American Gastrointestinal and Endoscopic Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Mohamed Akoad, MD, Liver Transplant Surgeon, Division of Hepatobiliary and Liver Transplantation, Department of Surgery, Veterans Administration Pittsburgh Healthcare System
Disclosure: Nothing to disclose.

Richard W Golub, MD, FACS, Consulting Surgeon, Sarasota Memorial Hospital and Doctors Hospital; Consulting Surgeon, Intercoastal Medical Group
Richard W Golub, MD, FACS is a member of the following medical societies: American College of Gastroenterology, American College of Surgeons, American Society for Gastrointestinal Endoscopy, American Society of Colon and Rectal Surgeons, Association for Academic Surgery, Association for Surgical Education, Crohns and Colitis Foundation of America, Society for Surgery of the Alimentary Tract, and Society of American Gastrointestinal and Endoscopic Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Juan B Ochoa, MD, Assistant Professor, Department of Surgery, University of Pittsburgh
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

David L Morris, MD, PhD, Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia
Disclosure: RFA Medical None Director; MRC Biotec None Director

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA, Vice Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital
John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract
Disclosure: AMGEN Royalty Other

 
 
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