Gastric Volvulus


Article Author:
Peter Lopez


Article Editor:
Rishi Megha


Editors In Chief:
Sebastiano Cassaro
Joseph Lee
Tanya Egodage


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
5/2/2019 11:37:51 PM

Introduction

Gastric volvulus is a rare, clinical event that occurs in both adults and pediatric patients. In 1886, Berti was the first to describe a gastric volvulus after performing an autopsy on a female patient. A gastric volvulus occurs when the stomach rotates on itself at least 180 degrees along its transverse or longitudinal axis. Gastric strangulation is a complication that can occur after the development of acute gastric volvulus. Timely diagnosis and treatment of acute gastric volvulus can potentially decrease morbidity and mortality. Patients can simply present with mild abdominal pain associated with nausea and vomiting, without emesis. Other patients can present with sepsis from necrosis of their volvulus and similar chief complaints.[1][2]

Etiology

In 10% to 30% of cases, gastric volvulus is considered primary and results from laxity and disruption of the stomach's ligamentous attachments (gastrohepatic, gastrocolic, gastrolienal, and gastrophrenic). For the majority of cases, gastric volvulus is caused by a gastric, splenic, or diaphragmatic anatomic disorder, the most common being a diaphragmatic hernia or an abnormality in gastric function. The organoaxial rotation of the stomach as described by Singleton is the most common gastric volvulus (two-thirds of cases) and occurs when the stomach rotates around the pylorus and the gastroesophageal (GE) junction. Mesenteroaxial rotation is less common (one-third of cases), and occurs when the stomach rotates longitudinal line parallel to the gastrohepatic omentum.[3]

Epidemiology

Gastric volvulus occurs in children usually less than 1 year of age and occurs in older adults, those who are older than 50 years. There does not seem to a predilection for gastric volvulus for either gender or race. The most common cause of a gastric volvulus in both children and adults is a paraesophageal hernia.[4]

Pathophysiology

Gastric volvulus causes a foregut obstruction in the patients. Gastric volvulus may present either acutely, or it may present with intermittent, recurrent, and chronic symptoms. When the stomach twist on itself there is always a risk for stomach strangulation with necrosis, perforation, and shock. The mortality for an acute volvulus can range from 30% to 50%, thus highlighting the importance of early diagnosis and treatment of gastric volvulus.

History and Physical

A patient's clinical presentation depends on the speed of onset, the type of stomach rotation (volvulus), and the completeness of the foregut obstruction. The presentation of an acute gastric volvulus can be quite severe with acute epigastric abdominal pain associated with severe retching. In 1904, Borchardt described the triad of acute epigastric pain, retching with the inability to vomit, and the difficulty or inability to pass a nasogastric tube. This triad occurs in up to 70% of patients who present with an acute organoaxial volvulus. The nasogastric tube passes easily in patients who present with an acute mesenteroaxial volvulus, as the lower esophageal sphincter remains open. The opposite is appreciated with organoaxial volvulus, as the nasogastric tube is more difficult to pass, due to the involvement of more proximal structures including the lower esophageal sphincter, the fundus, or the cardia. Patients who present with chronic, intermittent, and vague signs and symptoms of upper abdominal pain, nausea, dysphagia, early satiety vomiting, and hiccups may have a chronic partial or intermittent gastric volvulus.

Evaluation

The diagnosis of a gastric volvulus can be suspected with a good history and physical exam; however, diagnosis can be difficult. The diagnosis of a gastric volvulus may be confirmed radiologically when patients are symptomatic. Plain chest x-ray films that are suspicious for a gastric volvulus are those that demonstrate a spherical stomach or a double air-fluid level on upright chest films and the retrocardiac air-fluid level above the diaphragm on lateral chest film. Albas et al. described 4 radiologic findings predictive for a gastric volvulus on an upper gastrointestinal (GI) contrast study by showing gastric air-fluid level above the diaphragm, a paucity of distal bowel gas, reversal of the relative position of the greater curvature of the stomach, and a downward pointing pylorus. A barium swallow may be helpful as an adjunct to chest x-ray. Computed tomography (CT) scans of the chest, abdomen, and pelvis can also be diagnostic. CT scan of the chest, abdomen, and pelvis can provide information about the nature of volvulus, and other intraabdominal organs that may be involved, thus assisting pre-operative planning.

Treatment / Management

The traditional treatment for a patient presenting with an acute gastric volvulus has been an immediate operation reducing and untwisting the volvulus. This remains the gold standard; however, attempted medical management may be useful in patients that are a very high risk for surgery. Immediate surgical resection is required for necrosis or perforation of the stomach. Simultaneously, the diaphragmatic hernia should be reduced and closed. The stomach is then fixed to the anterior abdominal wall with suture, or by the placement of a gastrostomy tube. Open surgery, or the combination of laparoscopic and endoscopic surgical techniques, have good results. Laparoscopy, when used to repair chronic and intermittent gastric volvulus, is often be less morbid than an open operation. Patients who are fit enough to undergo a surgical procedure should proceed to have their chronic gastric volvulus repaired because of the high morbidity and mortality (30% to 50%) associated with strangulated gastric volvulus.[5][6]

Good results have also been reported with conservative treatment of an acute gastric volvulus in elderly patients if they are not presenting in extremis. Conservative treatment has also been used to help patients with intermittent and chronic volvulus.  The patient should be kept sitting upright, and a nasogastric tube should be gently inserted to decompress the stomach. The patient should be adequately resuscitated and re-evaluated often. Some high-risk, elderly patients can be treated endoscopically with decompression and reduction of the stomach, and placement of a percutaneous gastrostomy tube to gastropexy the stomach to the abdominal wall. Percutaneous gastrostomy placement can be done as an adjunct in ill patients with chronic or intermittent volvulus, or that may have other critical issues that need to be handled before definitive surgery, for example, sepsis from another source.

Differential Diagnosis

The differential diagnosis for gastric volvulus is very broad. The following are potential differential diagnosis:

  • Gastroesophageal reflux disease
  • Peptic ulcer disease
  • Esophageal cancer
  • Esophageal motility disorders
  • Esophageal diverticulum
  • Gastric cancer
  • Gastroparesis

Enhancing Healthcare Team Outcomes

The diagnosis and management of gastric volvulus is complex and best done with a multidisciplinary team that includes a radiologist, emergency department physician, general surgeon, gastroenterologist, and an intensivist. Delay in diagnosis or treatment can be fatal. Some patients may be managed with conservative treatment that includes decompression of the stomach, but most patients benefit from surgery.

Strangulated gastric volvulus is associated with mortality rates in excess of 30% and these patients need monitoring by ICU nurses. Even after surgery, patients may develop complications that can prolong recovery. The outcomes for most patients are guarded.

 


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Gastric Volvulus - Questions

Take a quiz of the questions on this article.

Take Quiz
A 62-year-old female has had chronic recurrent episodes of upper abdominal pain for 2 years. It occurs about every 3 months. Upper endoscopy has shown mild gastritis that was treated with a proton pump inhibitor without improvement. Ultrasound and CT of the abdomen were normal. Which of the following would confirm the diagnosis of chronic gastric volvulus?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is the most likely diagnosis of a 1-month-old infant with bilious emesis and a double-bubble sign on an upper GI series?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 72-year-old male with a history of type III paraesophageal hernia presents to the emergency department complaining of sudden-onset, acute chest and epigastric abdominal pain. The pain is sharp in quality and radiates to the back. During this time he has had episodes of severe retching, but he has not passed any vomitus. He does not have any prior cardiovascular medical history nor risk factors. What has likely occurred and what is the next best step?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
An 87-year-old female presents to the emergency department with retching for two days and severe epigastric pain with distention. Her hemoglobin is 17 g/dL, and her WBC is 20,000/microL. Her lactate is 10 mmol/L. What is the incidence of her having an ischemic stomach from a gastric volvulus?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
In a patient with a suspected gastric volvulus by history and plain chest x-ray, when would endoscopy aid in confirming and possibly treating the patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the most common procedure performed to treat patients with a gastric volvulus for patients both adults and pediatric patients?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Gastric Volvulus - References

References

da Costa KM,Saxena AK, Management and outcomes of gastric volvulus in children: a systematic review. World journal of pediatrics : WJP. 2019 Mar 21;     [PubMed]
Takahashi T,Yamoto M,Nomura A,Ooyama K,Sekioka A,Yamada Y,Fukumoto K,Urushihara N, Single-incision laparoscopic gastropexy for mesentero-axial gastric volvulus. Surgical case reports. 2019 Feb 4;     [PubMed]
Verde F,Hawasli H,Johnson PT,Fishman EK, Gastric volvulus: unraveling the diagnosis with MPRs. Emergency radiology. 2019 Apr;     [PubMed]
Bauman ZM,Evans CH, Volvulus. The Surgical clinics of North America. 2018 Oct;     [PubMed]
Coe TM,Chang DC,Sicklick JK, Small bowel volvulus in the adult populace of the United States: results from a population-based study. American journal of surgery. 2015 Aug;     [PubMed]
Costa MRP,Matos ASB,Almeida JR,Oliveira FJ, Primary gastric volvulus: a report of two cases. Journal of surgical case reports. 2018 Aug;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Surgery-General. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Surgery-General, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Surgery-General, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Surgery-General. When it is time for the Surgery-General board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Surgery-General.