Gastric Volvulus Clinical Presentation

Updated: Apr 10, 2017
  • Author: William W Hope, MD; Chief Editor: John Geibel, MD, DSc, MSc, AGAF  more...
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Presentation

History

Gastric volvulus can manifest either 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

The Borchardt triad (ie, pain, retching, and inability to pass a nasogastric tube) is diagnostic of acute volvulus and reportedly occurs in 70% of cases. [8] Carter et al described three additional findings that are suggestive of gastric volvulus, as follows [6] :

  • Minimal abdominal findings when the stomach is in the thorax
  • Gas-filled viscus in the lower chest or upper abdomen on chest radiograph
  • Obstruction at the site of the volvulus on an upper gastrointestinal (GI) radiographic series

Hiccups have been reported to be a subtle sign in the clinical diagnosis of gastric volvulus. [20]

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. This condition is often associated with cardiopulmonary compromise from gastric distention and may mimic an acute myocardial infarction.

Progressive distention and nonproductive retching follow the pain. Patients may have upper abdominal distention and tenderness if the stomach remains intra-abdominal; however, if the stomach becomes intrathoracic, there may be minimal abdominal findings.

Occasionally, some patients present with hematemesis [21] secondary to mucosal ischemia and sloughing. This can rapidly progress to hypovolemic shock from loss of blood and fluids.

Chronic gastric volvulus

Patients with chronic gastric volvulus typically present with intermittent epigastric pain and abdominal fullness after meals. They 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.

An upper GI series can be diagnostic during an acute attack.

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Physical Examination

Physical examination findings in patients with gastric volvulus can be nonspecific and relate to the chronicity of the volvulus. Epigastric tenderness and distention can suggest gastric volvulus; in cases of stomach necrosis or severe obstruction, peritonitis can be present.

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Complications

Strangulation and necrosis are the most feared complications of gastric volvulus; they can be life-threatening and occur most commonly with organoaxial gastric volvulus (5-28% of cases). [6, 7] Gastric perforation occurs secondary to ischemia and necrosis and can result in sepsis and cardiovascular collapse; it can also complicate endoscopic reduction (see Treatment).

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