Introduction
Supine abdominal image shows a mesenteroaxial volvulus with gastric outlet obstruction. Reprinted with permission from the American Journal of Roentgenology, to be used only in the eMedicine Radiology article Gastric Volvulus.
Upright abdominal image obtained in the same patient as in Image above shows a mesenteroaxial volvulus with gastric outlet obstruction. Reprinted with permission from the American Journal of Roentgenology, to be used only in the eMedicine Radiology article Gastric Volvulus.
Background
Gastric volvulus (Latin volvere, to roll) is rotation of all or part of the stomach by more than 180º, which may lead to a closed-loop obstruction and possible strangulation.1
Symptoms may range from mild abdominal pain and vomiting, when no or partial outlet obstruction is present, to severe pain and retching, when there is complete obstruction and ischemia.2
For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles Abdominal Pain in Adults and Barium Swallow.
Related eMedicine topics:
Volvulus
Gastric Volvulus (General Surgery)
Disorders of Rotation/Fixation and Midgut Volvulus
Midgut Volvulus
Volvulus, Sigmoid and Cecal
Mortality/Morbidity
The mortality rate for acute gastric volvulus is reportedly 42-56%. The mortality rate for chronic gastric volvulus is 10-13%.
Reported complications include the following:
- Ulceration
- Perforation
- Hemorrhage
- Pancreatic necrosis
- Omental avulsion
- Splenic rupture
Race
No racial predilection is reported.
Sex
Generally, the prevalence rates are considered equal in males and females. However, at least 1 study shows a female predilection.
Age
Gastric volvulus occurs in persons of any age, although the incidence peaks in those aged 40-50 years. Approximately 20% of cases occur in infants younger than 1 year.3
Presentation
Natural history and presentation
Primary and secondary forms
The primary and secondary forms of gastric volvulus are associated with laxity of the supporting structures of the stomach. The gastrophrenic, gastrohepatic, gastrosplenic, and gastrocolic ligaments hold the stomach in place at the esophageal hiatus and pylorus. These ligaments allow significant gastric mobility but normally never permit more than 180º of rotation.
(Click Image to enlarge.) Normal ligamentous attachments of the stomach.
Typically, laxity increases with age, and it may be more common in females than in males. In neonates, these ligaments may be absent or abnormally loose, resulting in volvulus. In the older child, gastric distention with air or fluid as a result of pyloric hypertrophy, pyloric stenosis, or air swallowing may cause ligamentous laxity and volvulus.
Gastric volvulus is classified on the basis of its location in reference to the diaphragm and on the basis of the axis of rotation. Subdiaphragmatic, or primary, volvulus accounts for approximately one third of cases, and it is not associated with diaphragmatic defects. Supradiaphragmatic, or secondary, volvulus accounts for approximately two thirds of cases, and it is associated with diaphragmatic defects. Predisposing factors occur with this type of volvulus in more than 50% of cases and include paraesophageal hiatal hernias, diaphragmatic eventration, diaphragmatic trauma, diaphragmatic paralysis from phrenic nerve injury, gastric ulcer or neoplasm, extrinsic pressure from enlarged adjacent organs or masses, and abdominal adhesions.
Classification based on axis of rotation
Gastric volvulus is also classified on the basis of its axis of rotation. In the more common, organoaxial volvulus (59% of cases), the stomach rotates on its longitudinal axis. This axis is defined as the line connecting the cardia and pylorus. The greater curvature moves from an inferior to a superior position. Compared with the other types of gastric volvulus, organoaxial volvulus is more commonly associated with strangulation. Because of the rich vascular supply of the stomach, strangulation occurs in only 5-28% of cases.
In mesenteroaxial volvulus (29% of cases), the stomach rotates about a vertical axis passing through the middle of the greater and lesser curvatures. The pylorus moves anteriorly and superiorly, whereas the greater curvature remains inferior. Mesenteroaxial volvulus is more often seen in young children and is associated with ligamentous laxity but not with diaphragmatic defects.
In both of these classifications, the configuration of the stomach may be characterized as upside down. The remaining cases demonstrate features of organoaxial and mesenteroaxial volvulus (2%), or they are unclassified (10%).
Signs and symptoms
The signs and symptoms of gastric volvulus depend on the condition's type (primary or secondary) and chronicity, as well as the degree of obstruction.4
Chronic volvulus may be detected incidentally on plain chest radiographs or on upper gastrointestinal (GI) series. Symptoms and signs include the following:
- Vague, intermittent abdominal pain
- Chest pain in secondary cases
- Early satiety
- Upper abdominal fullness
- Dysphagia
- Dyspnea
- Obstructive jaundice
- Bowel sounds in the chest
Acute cases represent a surgical emergency. Typical symptoms and signs are described by noting the Borchardt triad:
- Severe upper abdominal pain and distention
- Violent retching with an inability to vomit
- Inability to pass a nasogastric tube into the stomach
Treatment
Reduction of acute gastric volvulus is first attempted with nasogastric decompression. This is often unsuccessful, however, particularly in cases of organoaxial volvulus with obstruction. Surgical goals include reduction, the prevention of recurrence, and the repair of predisposing factors. Specifically, treatment involves anterior gastropexy or gastrostomy in order to fix the stomach in its anatomically correct position or involves partial or total gastrectomy in the setting of necrosis or carcinoma. Diaphragmatic defects may be repaired with fundoplication. Laparoscopic techniques have been used as well.4
Chronic gastric volvulus may be treated by using the aforementioned surgical techniques. However, in primary cases without diaphragmatic defects, endoscopic reduction with percutaneous endoscopic gastrostomy fixation has been successful. Some authors argue that surgical intervention is necessary in these cases only when endoscopic management fails or when the volvulus recurs.
Although radiologic interventions are not commonly used, they are potentially useful interventional strategies. Several authors advocate palliative stenting for obstructions of the gastric outlet in patients who are not candidates for surgery. Under combined fluoroscopic and endoscopic guidance via a perioral route, the self-expanding vascular Wallstent has been placed successfully in patients with malignant or benign gastric outlet obstructions. Although its use with gastric volvulus has not been documented, this intervention may be useful in the setting of obstruction secondary to volvulus.
Preferred Examination
The definitive diagnosis of gastric volvulus resides with the radiologist. Typically, the first examination to be performed in the patient with symptoms referable to the chest and/or abdomen is a plain radiograph. Although this is a good examination to start with, the most definitive study is the upper GI barium study.4,5
Limitations of Techniques
Plain radiography may demonstrate findings that are indistinguishable from those that are produced by other causes of gastric atony or obstruction. However, the modality is useful for excluding other causes of the patient's symptoms, such as pneumoperitoneum or pneumothorax.
Barium study is highly sensitive and specific. However, the diagnosis may be missed in cases of intermittent torsion.
Fiberoptic endoscopy has a limited role in the diagnosis of gastric volvulus because the twist precludes passage of the endoscope.
Laboratory studies are generally unrewarding, although levels of amylase and alkaline phosphatase may be increased.
Differential Diagnoses
Cholecystitis, Acute
Duodenum, Ulcers
Esophagus, Tear
Gastric Ulcer
Myocardial Infarct, Acute
Pancreatitis, Acute
Other Problems to Be Considered
In chronic gastric volvulus - Chronic cholecystitis, ischemic heart disease
In acute gastric volvulus - Acute gastric dilatation, gastric outlet obstruction, perforated peptic ulcer, ruptured gallbladder
More on Gastric Volvulus |
 Overview: Gastric Volvulus |
| Imaging: Gastric Volvulus |
| Follow-up: Gastric Volvulus |
| Multimedia: Gastric Volvulus |
| References |
| Further Reading |
| Next Page » |
References
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Further Reading
Related eMedicine topics:
Volvulus
Gastric Volvulus (General Surgery)
Disorders of Rotation/Fixation and Midgut Volvulus
Midgut Volvulus
Volvulus, Sigmoid and Cecal
Keywords
gastric volvulus, gastric torsion, closed-loop obstruction, gastric strangulation, gastric rotation, subdiaphragmatic volvulus, primary volvulus, supradiaphragmatic volvulus, mesenteroaxial volvulus, secondary volvulus
