Gastric Volvulus Workup

Updated: Apr 11, 2017
  • Author: William W Hope, MD; Chief Editor: John Geibel, MD, DSc, MSc, AGAF  more...
  • Print
Workup

Approach Considerations

Biochemical tests usually are not diagnostic for gastric volvulus; however, hyperamylasemia and elevated serum alkaline phosphatase have been reported. [22] There has also been a report of hyperamylasemia in gastric volvulus leading to a missed diagnosis of pancreatitis. [23]

Imaging studies, such as radiography (plain film and barium contrast) and computed tomography (CT), confirm the diagnosis. Findings on upper gastrointestinal (GI) endoscopy may be suggestive of gastric volvulus.

Next:

Plain and Contrast Radiography

Chest

On chest radiography, a retrocardiac gas-filled viscus may be seen in cases of intrathoracic stomach, which confirms the diagnosis.

Abdomen

Plain abdominal radiography reveals a massively distended viscus in the upper abdomen. In organoaxial volvulus, plain films may show a horizontally oriented stomach with a single air-fluid level [24] and a paucity of distal gas. [25] In mesenteroaxial volvulus, plain abdominal radiographic findings include a spherical stomach on supine images and two air-fluid levels on erect images, with the antrum positioned superior to the fundus. [7]

Upper gastrointestinal tract

The diagnosis of gastric volvulus is usually based on barium studies, [26, 27] though some authors recommend CT (see below) as the imaging modality of choice. [28, 29] Upper GI contrast radiographic studies (using barium or diatrizoate meglumine–diatrizoate sodium) are sensitive and specific if performed with the stomach in the twisted state [29] and may show an upside-down stomach. Contrast studies have been reported to have a diagnostic yield in 81-84% of patients. [18, 27, 30, 31]

Previous
Next:

Computed Tomography

Often performed for an evaluation of acute abdominal pain, CT can offer an immediate diagnosis by showing two bubbles with a transition line. Proponents of CT in the diagnosis of gastric volvulus report several benefits, including the following [29, 32] :

  • Ability to diagnose the condition rapidly on the basis of a few coronal reconstructed images
  • Ability to detect the presence or abscess of gastric pneumatosis and free air
  • Ability to detect predisposing factors (eg, diaphragmatic or hiatal hernias)
  • Ability to exclude other abdominal pathology

In a study that included 10 patients with acute gastric volvulus, Millet et al determined the following two findings to be the most sensitive direct signs of gastric volvulus on CT [33] :

  • Antropyloric transition point without any abnormality at the transition zone
  • Antrum at the same level as or higher than the fundus

The presence of both CT findings was 100% sensitive and specific for the diagnosis of gastric volvulus. [33]

Previous
Next:

Endoscopy

Upper GI endoscopy may be helpful in the diagnosis of gastric volvulus. When this procedure reveals distortion of the gastric anatomy with difficulty intubating the stomach or pylorus, it can be highly suggestive of gastric volvulus. [29] In the late stage of gastric volvulus, strangulation of the blood supply can result in progressive ischemic ulceration or mucosal fissuring. [34]

Previous