eMedicine Specialties > Radiology > Gastrointestinal
Gastric Volvulus
Updated: Dec 22, 2008
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
Radiography
Supine abdominal image shows a mesenteroaxial volvulus with a typical beak (arrow). Reprinted with permission from the American Journal of Roentgenology, to be used only in the eMedicine Radiology article Gastric Volvulus.
Frontal chest image shows 2 air-fluid levels, 1 below the left hemidiaphragm and 1 retrocardiac, in a patient with paraesophageal hiatal hernia complicated by gastric volvulus. Reprinted with permission from the American Journal of Roentgenology, to be used only in the eMedicine Radiology article Gastric Volvulus.
Findings
Mesenteroaxial volvulus
In mesenteroaxial volvulus, the distended stomach appears spherical on supine images. Two air-fluid levels are visible on the upright film: 1 in the fundus, which is inferior, and 1 in the antrum, which is superior. In addition, the upright image often demonstrates a beak where the esophagogastric junction is seen on normal images. If a nasogastric tube is passed, the esophagogastric junction is seen inferior to its normal location. If barium moves past the esophagogastric junction, the upside-down configuration of the stomach and the degree of obstruction can be documented.
Organoaxial volvulus
Organoaxial volvulus is difficult to diagnose on plain images. The stomach lies horizontally and contains a single air-fluid level on upright views. No characteristic beak is observed. Decreased air is noted within the remaining GI tract. Barium study shows that the esophagogastric junction is lower than normal. Marked gastric dilatation and the slow passage of contrast material past the site of twisting are noted.
Degree of Confidence
Plain radiographic findings that are suggestive of gastric volvulus should be confirmed with a barium study.
False Positives/Negatives
Although the classic plain radiographic findings described above are suggestive of volvulus, a false-negative diagnosis may result if the twisted stomach is filled with fluid. A distended, air-filled stomach may result secondary to other causes of gastric obstruction, leading to a false-positive diagnosis.
The barium study is highly sensitive and specific for gastric volvulus. It is generally considered to be the criterion standard for diagnosis. However, as stated above, the diagnosis may be missed in cases of intermittent torsion. The upper GI series may show only a paraesophageal hernia or eventration of the diaphragm during a symptom-free interval, leading to a false-negative diagnosis.
Computed Tomography
Findings
The computed tomography (CT) scanning and magnetic resonance imaging (MRI) appearance of gastric volvulus can be variable. The extent of diaphragmatic herniation, the points of torsion, and the final position of the stomach determine the appearance.6,7
Degree of Confidence
CT scanning and MRI are not typically considered to be the diagnostic examinations of choice in patients who are evaluated for gastric volvulus. However, some experts argue that the multiaxial reconstructions that are afforded by helical CT in particular may be preferred to the images obtained with conventional barium study, particularly in the acutely ill patient who is unable to tolerate a fluoroscopic examination. In addition, chronic gastric volvulus is often discovered incidentally in patients undergoing CT scanning for an unrelated condition. In most patients, CT-scan or MRI findings that suggest a gastric volvulus should be confirmed with an upper GI series.
False Positives/Negatives
Without torsion, gastric volvulus may be difficult to distinguish from paraesophageal hiatal hernia, and false-positive, as well as false-negative, diagnoses can result.
Ultrasonography
Findings
A study has demonstrated the peanut sign in a case of chronic gastric volvulus. The ultrasonographic features consist of a constricted segment of stomach, with 2 dilated segments located above and below the constricted part, akin to a peanut.8
Degree of Confidence
Ultrasonography is a noninvasive modality that can be performed on debilitated patients relatively easily and repeatedly; it requires no specific preparation. However, ultrasonography as a technique for the detection of gastric disease (and of gastric volvulus in particular) is still in its infancy. In several case reports, the ultrasonographic evaluation of gastric volvulus shows normal findings. Until more data are available, upper GI series should be used to confirm the diagnosis.
Nuclear Imaging
Findings
Gastric volvulus may be discovered during scintigraphic examination, sometimes incidentally, as the cause of a patient's symptoms. In 1 case report, a technetium-99m pertechnetate Meckel scan obtained to assess chronic GI bleeding in a child demonstrated an intrathoracic stomach with the greater curvature superior to the lesser curvature. Another case report demonstrated similar findings during an iodine-131 whole-body scan in a patient with metastatic thyroid cancer. In each case, upper GI series confirmed an organoaxial volvulus.
Degree of Confidence
Scintigraphic evidence of gastric volvulus should be confirmed with an upper GI series.
Angiography
Findings
During an episode of gastric volvulus, the arteries supplying the stomach are displaced according to the position of the stomach. Typically, the right and left gastroepiploic arteries are displaced high beneath the left hemidiaphragm. The right gastroduodenal artery also is displaced, and the left gastric artery appears to be coiled and shortened.
Degree of Confidence
Angiography is often used in the evaluation of massive or refractory GI hemorrhage. Although it is a rare cause of such hemorrhage, gastric volvulus should be considered. The angiographic appearance is sensitive and specific during an acute episode.
Intervention
Medicolegal Pitfalls
- The diagnosis of gastric volvulus should be considered in patients presenting with abdominal or chest pain or with other vague GI complaints.
- Erroneous diagnoses of myocardial ischemia, cholelithiasis, and pancreatitis are common.
- Acute gastric volvulus can be lethal, and the diagnosis must not be overlooked.
Multimedia
Media file 1: (Click Image to enlarge.) Normal ligamentous attachments of the stomach.
Media file 2: 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.
Media file 3: 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.
Media file 4: Supine abdominal image shows a mesenteroaxial volvulus with a typical beak (arrow). Reprinted with permission from the American Journal of Roentgenology, to be used only in the eMedicine Radiology article Gastric Volvulus.
Media file 5: Upright abdominal image obtained in the same patient as in Image 4 shows a mesenteroaxial volvulus. Reprinted with permission from the American Journal of Roentgenology, to be used only in the eMedicine Radiology article Gastric Volvulus.
Media file 6: Image from an upper gastrointestinal series obtained in the same patient as in Images 4-5 shows a mesenteroaxial volvulus. Reprinted with permission from the American Journal of Roentgenology, to be used only in the eMedicine Radiology article Gastric Volvulus.
Media file 7: Frontal chest image shows 2 air-fluid levels, 1 below the left hemidiaphragm and 1 retrocardiac, in a patient with paraesophageal hiatal hernia complicated by gastric volvulus. Reprinted with permission from the American Journal of Roentgenology, to be used only in the eMedicine Radiology article Gastric Volvulus.
Media file 8: Lateral chest image obtained in the patient in Image 7. Reprinted with permission from the American Journal of Roentgenology, to be used only in the eMedicine Radiology article Gastric Volvulus.
Media file 9: Frontal chest image obtained in the same patient as in Images 7-8, 2 days later. An additional air-fluid level is present on the left side of the chest. Reprinted with permission from the American Journal of Roentgenology, to be used only in the eMedicine Radiology article Gastric Volvulus.
Media file 10: Image from an upper gastrointestinal series, obtained in the same patient as in Images 7-9, shows a gastric volvulus with obstruction at the outlet of a rotated herniated segment. Reprinted with permission from the American Journal of Roentgenology, to be used only in the eMedicine Radiology article Gastric Volvulus.
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Keywords
gastric volvulus, gastric torsion, closed-loop obstruction, gastric strangulation, gastric rotation, subdiaphragmatic volvulus, primary volvulus, supradiaphragmatic volvulus, mesenteroaxial volvulus, secondary volvulus
Contributor Information and Disclosures
Author
Jeremy Green, MD, Attending Physician, Department of Radiology, New York Methodist Hospital
Jeremy Green, MD is a member of the following medical societies: American College of Radiology
Disclosure: Nothing to disclose.
Coauthor(s)
Marjorie Stein, MD, Clinical Assistant Professor of Radiology, Albert Einstein College of Medicine; Consulting Staff, Department of Radiology, Montefiore Medical Center
Marjorie Stein, MD is a member of the following medical societies: American College of Radiology, American Institute of Ultrasound in Medicine, and Radiological Society of North America
Disclosure: Nothing to disclose.
Medical Editor
Neela Lamki, MD, Professor, Department of Radiology, Sultan Qaboos University, Oman; Adjunct Professor, Department of Radiology, Baylor College of Medicine
Disclosure: Nothing to disclose.
Pharmacy Editor
Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.
Managing Editor
Abraham H Dachman, MD, FACR, Professor, Department of Radiology, The University of Chicago School of Medicine; Director of CT, Department of Radiology, The University of Chicago Hospitals
Abraham H Dachman, MD, FACR is a member of the following medical societies: Radiological Society of North America
Disclosure: iCAD, Inc. Consulting fee Consulting; iCAD, Inc. Grant/research funds Other; GE Healtcare, Inc. Honoraria Speaking and teaching
CME Editor
Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.
Chief Editor
Eugene C Lin, MD, Consulting Radiologist, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology, University of Washington School of Medicine
Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, and Society of Nuclear Medicine
Disclosure: Nothing to disclose.