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Gastric Volvulus

Stomach Volvulus

Gastric volvulus is a rare medical condition in which the stomach rotates on its mesentery. There are different etiologies and varied clinical presentations of this type of volvulus. Furthermore, it is associated with serious sequelae and therefore warrants prompt diagnosis and treatment.


Presentation

The clinical picture is varied according to the degree of rotation. While mild symptoms of gastric volvulus may resemble benign abdominal conditions, the serious cases feature worrisome symptoms.

Acute

In acute presentations of gastric volvulus, the main features are severe abdominal pain, retching, and an inability to pass a nasogastric tube into the stomach [2]. An intraabdominal gastric volvulus manifests as a sudden onset of pain in the epigastric or left upper quadrant region. An intrathoracic gastric volvulus will present as sharp pain in the chest that radiates to the left side of the neck, shoulder, arms and back.

Other signs include hiccups and even hematemesis of which the latter can lead to hypovolemic shock.

Chronic

In longstanding cases of gastric volvulus, patients experience intermittent epigastric pain accompanied by post meal abdominal fullness and distension. Further symptoms include early satiety, chest pain, dyspnea, and dysphagia.

Painful Cough
  • Patients with acute gastric volvulus on diaphragmatic hernia are a diagnostic and therapeutic emergency.Here, we report a case of a 56-year-old woman diagnosed with epigastric pain, cough, vomiting since 2 weeks and shortness of breath.[ncbi.nlm.nih.gov]
Foreign Body Aspiration
  • The acute presentation of respiratory distress was initially concerning for a foreign body aspiration, but a chest radiograph demonstrated left-sided opacification and mediastinal shift to the right.[ncbi.nlm.nih.gov]
Wheelchair Bound
  • A 55-year-old wheelchair-bound woman with severe cerebral palsy was found at autopsy to have marked distention of the stomach due to a volvulus.[ncbi.nlm.nih.gov]
Internal Bleeding
  • Sometimes severe pain at the top of left shoulder, this may be due to internal bleeding irritating the diaphragm upon respiration.[en.wikipedia.org]
Abdominal Pain
  • A previously healthy 6-year-old female presented to the emergency department in the middle of the night after sudden onset of vomiting and abdominal pain.[ncbi.nlm.nih.gov]
  • Gastric volvulus is a rare condition that is typically characterised by abdominal pain and unproductive retching. The volvulus occurs around an axis formed by two fixed points, organoaxial or mesenteroaxial.[ncbi.nlm.nih.gov]
  • An 80-year-old male patient with a history of a hiatus hernia presented with acute abdominal pain and vomiting. CT of his abdomen revealed extraluminal free gas consistent with a perforation. He had a large hiatus hernia.[ncbi.nlm.nih.gov]
  • We present a rare case of 80 years old female with vague upper abdominal pain and recurrent vomiting.[ncbi.nlm.nih.gov]
  • Approximately 5 hours after discharge, the patient returned to the pediatric ED with worsening abdominal pain, the inability to tolerate oral intake, and a firm and distended abdomen.[ncbi.nlm.nih.gov]
Epigastric Pain
  • Gastric volvulus (GV) is a rare condition that presents with epigastric pain, retching and at times, vomiting. There are two types of GV: organoaxial and mesenteroaxial.[ncbi.nlm.nih.gov]
  • Traditionally Borchardt's triad is believed to be diagnostic for acute gastric volvulus and consists of unproductive retching, epigastric pain and distention, and the inability to pass a nasogastric tube.[ncbi.nlm.nih.gov]
  • A 38-year-old woman presented with epigastric pain and EGD showed pangastritis. Immediately after EGD she developed increased severity of pain, vomiting and abdominal distension.[ncbi.nlm.nih.gov]
  • We report a rare case of a 23-year-old man who presented with a 1-day history of vomiting, epigastric pain, distention, and constipation.[ncbi.nlm.nih.gov]
  • He had complained of retching and associated epigastric pain prior to collapse, and had sustained a motorcycle accident approximately 60 years earlier.[ncbi.nlm.nih.gov]
Abdominal Distension
  • We report a neonate who presented with failure to thrive, non-bilious vomiting and upper abdominal distension starting at one week of age.[ncbi.nlm.nih.gov]
  • Immediately after EGD she developed increased severity of pain, vomiting and abdominal distension.[ncbi.nlm.nih.gov]
  • Acute gastric volvulus resulting in abdominal compartment syndrome was determined to be the cause of death in a 4-year-old girl who presented with abdominal distension.[ncbi.nlm.nih.gov]
  • A 2.5-year-old boy was referred to the emergency room for a sudden onset of diffuse and increasing abdominal pain with lethargy, abdominal distension, and vomiting, all in the past 24 hours. A plain abdominal X-ray showed gastric distension.[ncbi.nlm.nih.gov]
  • The commonest symptom was abdominal distension. Two patients were diagnosed by barium studies and six had clinical suspicion because of their symptoms and were confirmed intra-operatively.[ncbi.nlm.nih.gov]
Acute Abdomen
  • Herein, we report a case having wandering spleen with torsion, and gastric and distal pancreatic volvulus, an unusual triad in acute abdomen in an emergency setting, which has never been described before to the best of our knowledge.[ncbi.nlm.nih.gov]
  • Gastric volvulus is a rare condition in children and requires prompt diagnosis and urgent intervention in acute presentation where it mimics acute abdomen and strong clinical suspicion.[ncbi.nlm.nih.gov]
  • Abdominal US done initially in a patient with acute abdomen may show presence of spleen in an anomalous position, as seen in our case.[saudijgastro.com]
  • Pancreatic volvulus with wandering spleen and gastric volvulus: An unusual triad for acute abdomen in a surgical emergency. Saudi J Gastroenterol. 2014; 20(3): 195-8.[pancreas.imedpub.com]
  • Acute abdomen due to gastric volvulus: Diagnostic value of a single plain radiograph. PediatrRadiol. 1995;25Suppl. 1:S240. C oulier B, Ramboux A. Acute obstructive gastric volvulus diagnosed by helical CT. JBR-BTR. 2002;85:43.[casereports.in]
Hypotension
  • She underwent laparotomy revealing gangrenous gastric fundus perforation complicated by persistent intraoperative hypotension.[ncbi.nlm.nih.gov]
Fear
  • Ischemic necrosis is a feared complication of acute gastric volvulus, occurring in 11% of patients presenting with the condition and responsible for mortality in 30%. In such cases, there are few well-validated options for surgical reconstruction.[ncbi.nlm.nih.gov]

Workup

A person with a clinical presentation such as that of acute gastric volvulus warrants an urgent evaluation composed of a full history, a thorough physical examination including cardiac and abdominal assessment, and diagnostic studies.

Imaging

A confirmatory finding on chest radiograph in intrathoracic gastric volvulus is a gas-filled viscus. Abdominal radiographs will display a distended viscus in the upper abdomen. Furthermore, an organoaxial volvulus on abdominal x-ray is depicted as a horizontally positioned stomach with a single air-fluid level [8] whereas a mesenteroaxial volvulus is seen as a spherical stomach with 2 air-levels.

Upper GI contrast radiographs are very useful when the stomach is rotated. Specifically, this test demonstrates sensitivity and specificity [9], as it diagnoses 81% to 84% of cases.

CT imaging provides a prompt diagnosis as it portrays 2 bubbles with a transition line. Advocates for this study report that CT scans offer rapid results and detect other existing pathologies.

Upper GI endoscopy can be beneficial as well since its images will demonstrate the presence of distorted anatomy, strangulation, ulceration, and other late stage features [9].

Other

Note that patients with symptoms suggestive of cardiac disease will require a cardiac workup to exclude cardiac pathologies.

Mediastinal Shift
  • The stomach was viable, and filled with air and fluid and had pushed the left dome of the diaphragm upwards causing marked compression of the left lung with a mediastinal shift to the right (including the heart).[ncbi.nlm.nih.gov]
  • The acute presentation of respiratory distress was initially concerning for a foreign body aspiration, but a chest radiograph demonstrated left-sided opacification and mediastinal shift to the right.[ncbi.nlm.nih.gov]
  • Fig 1 Plain semi‐erect chest radiograph of the patient showing gas‐filled bowel with a fluid level in the left hemithorax, right mediastinal shift and gas beneath the right hemidiaphragm.[academic.oup.com]
Mediastinal Mass
  • Acute gastric volvulus was diagnosed by chest radiograph, upper digestive tract radiograph and CT scan; later type B3 thymoma was diagnosed by biopsy of mediastinal mass.[ncbi.nlm.nih.gov]
  • mass, pneumatocoele or pulmonary consolidation, making diagnosis difficult.[academic.oup.com]

Treatment

Acute gastric volvulus is associated with a high mortality rate that can be close to 80% [10]. Hence, this is considered an emergency that requires urgent surgical intervention. In chronic cases, surgery should be done as a preventive measure to avoid complications.

The surgical procedure aims to decompress, reduce, and prevent recurrence of the condition. The etiology, presence of defects and the exact anatomy of the volvulus will all be taken into account during the surgical planning phase.

The surgeon will perform the appropriate procedures which may include repair of the diaphragm, repair of existing diaphragmatic hernia, gastropexy (whether simple or complex), partial gastrectomy, or fundoantral gastrogastrostomy [11].

With regards to the surgical approach, minimally invasive techniques such as laparoscopy offer a smaller risk of complications in comparison to open surgery [12]. Furthermore, the advances made in laparoscopic surgical techniques are linked to more favorable outcomes in both acute and chronic cases [12].

Note that open surgery is necessary for patients with peritonitis or hemodynamic instability.

Prognosis

Acute cases of gastric volvulus are life-threatening and associated with a 30% to 50% fatality rate. In these cases, death has been attributed to strangulation, which results in necrosis and perforation of the stomach. Early diagnosis and intervention has reduced the mortality rate of acute volvulus to 15% to 20% and chronic cases to 0% to 13% [7].

Etiology

Prior to discussing the causes of volvulus, it is important to understand the natural functioning and anatomy of the stomach. Normally, this organ contracts and relaxes as it breaks down food and facilitates digestion. During contractions and relaxations, the stomach moves but its movement is limited by the ligaments, nearby organs such as the spleen, and the omentum.

There are 2 types of gastric volvulus. Type 1, which is idiopathic, is the most predominant variety and is observed in adults. Some believe this is secondary to previously taut ligaments of the stomach becoming lax. These structures are the gastrosplenic, gastroduodenal, gastrophrenic, and gastrohepatic ligaments. Note that their role is to sustain the position of the stomach in the abdominal cavity.

The second type, which is found mostly in children, is comprised of congenital and acquired etiologies that contribute to the abnormal movement of the stomach. Examples of causes include 1) defects of the diaphragm (a structure that overlays the stomach), 2) adhesions or bands connected to the stomach, and 3) absence of the spleen, which results in less support for the stomach [1].

Epidemiology

This disorder overall is rare. Its incidence is predominantly observed in adults over 50 as 80% to 90% of affected individuals are adults [2].

Note that more than 50% of pediatric cases occur in children younger than 12 months of age.

With regards to the patient demographics, gastric volvulus has not been correlated with race or gender.

Sex distribution
Age distribution

Pathophysiology

The pathophysiology of gastric volvulus centers around the plane of rotation [3]. Organoaxial gastric volvulus accounts for almost 60% of cases [4]. This occurs when the segments of the stomach, known as the antrum and fundus, rotate in opposite directions. To explain further, the stomach twists around its main plane. This has been associated with strangulation and necrosis in 5%-28% of patients [5] and is likely secondary to a diaphragmatic defect.

The mesentericoaxial variant involves the axis that covers the lesser and greater curvatures. Specifically, the antrum intermittently rotates in an anterior and superior manner thereby allowing the posterior side of the stomach to face anteriorly (albeit not a complete rotation). This type is observed in almost 29% of patients [4]. These patients experience chronic symptoms but do not suffer from vascular complications.

There is another category known as the combined type, which is chronic and rare. As the name suggests, the stomach rotates organoaxially and mesentericoaxially. This etiology is responsible for the remaining percentage of patients [6].

Prevention

Dietary modifications are recommended for individuals with gastric volvulus both before and after treatment. For example, they should eat multiple small meals as opposed to a large meal per day. This will allow them to digest the food and extract the nutrients more efficiently. Also, post-surgery patients should avoid fried or spicy food and foods that contain fiber. To prevent constipation, increased water intake is necessary. Finally, patients who undergo partial removal of stomach or intestine may be deficient in electrolytes and vitamins. Hence, they should adhere to the replacement of these substances.

Summary

Gastric volvulus, or twisted stomach, occurs when the stomach rotates more than 180º. This rare condition is characterized by an abnormal movement of the stomach that is likely to result in the compression and compromise of the blood vessels perfusing the organ. Hence, strangulation and necrosis of affected parts of the stomach are serious potential consequences. Some of the common factors predisposing to gastric volvulus include a hiatal hernia, asplenism, a defective diaphragm,etc.

There are 2 classes of gastric volvulus according to the etiology. Type 1 is idiopathic and mainly found in adults whereas type 2 is congenital or acquired and is observed in children. Overall, gastric volvulus occurs mostly in adults and has no preference for gender or race.

The clinical picture of gastric volvulus varies and may feature symptoms that mimic digestive disorders. In acute cases, the presentation may include severe abdominal pain, radiating chest pain, retching, and other similar manifestations. Chronic cases reveal nonspecific symptoms such as intermittent epigastric pain, abdominal fullness, distension, dysphagia, etc.

Early diagnosis and intervention are paramount as untreated gastric volvulus has a high mortality rate. A complete workup is composed of the patient's history, physical examination, and key imaging studies including computed tomography (CT) imaging, radiography, and upper gastrointestinal (GI) series with contrast. These diagnostic techniques offer confirmation with characteristic findings.

Whether acute or chronic, the therapeutic approach of gastric volvulus involves the surgical correction of the volvulus in addition to the repair of associated defects that are responsible for the abnormal rotation of the stomach. Due to surgical advances, laparoscopic techniques are preferred to open surgery. Note that the surgical treatment is vital to prevent complications.

Patients are advised to adhere to dietary restrictions and modifications such as consuming smaller meals, avoiding fiber and fried foods, replenishing vitamins and electrolytes, and increasing the intake of water to prevent constipation.

Patient Information

What is gastric volvulus?

This is an abnormal medical condition that occurs when the stomach rotates around itself. It can cause serious complications such as blockage and compromise of the stomach blood supply.

Who is affected?

This condition is more common in adults particularly the elderly.

About 20% of cases affect children, especially in babies under 1 year of age.

What are the causes of gastric volvulus?

The stomach twists around itself when the neighboring organs and structures are defective or absent. For example, patients may have a hiatal hernia, which is a condition caused by the upper part of the stomach entering the chest region.

Gastric volvulus is also caused when:

  • the Spleen is absent
  • there are defects of the diaphragm
  • Ligaments of the gastrointestinal system are long
  • there is a Stomach tumor
  • Muscles are weak e.g. in motor neuron disease

What are the signs and symptoms?

Depending on the degree of twisting, some patients may have mild symptoms and others will have more severe ones. The main features may include:

How is it diagnosed?

The clinician will ask the pertinent questions about the patient's symptoms and history to understand the full picture. Also, s/he will perform a physical exam and then order very important tests to determine the diagnosis.

The diagnostic studies include CT scans and/or x-rays. The CT images and x-rays typically confirm the diagnosis of gastric volvulus. Abdominal x-rays using barium contrast are also very helpful.

How is this condition treated?

In acute situations. the patient requires emergency surgery as the risk of death is very high if not recognized early and treated promptly. The surgery involves the untwisting of the stomach as well as repairing defects that caused the gastric volvulus in the first place. The surgical procedure(s) can be done either with an open incision or laparoscopically. Note that laparoscopic surgery results in better outcomes and lesser complications.

In chronic cases, the surgery is performed to prevent complications such as the death of tissue and compromise of blood supply.

Are there specific recommendations for patients with gastric volvulus?

For all patients, whether before or after surgery, there are special dietary restrictions as the patients are advised to:

  • Eat smaller meals as opposed to one big meal per day
  • Eat bland diets
  • Avoid food rich in fiber such as apples, broccoli, etc
  • Avoid fried and spicy foods
  • Prevent constipation by drinking plenty of water
  • Replace electrolytes and vitamins as needed

References

Article

  1. Miller DL, Pasquale MD, Seneca RP, Hodin E. Gastric volvulus in the pediatric population. Archives of Surgery. 1991; 126(9):1146-9.
  2. Wu MH, Chang YC, Wu CH, et al. Acute gastric volvulus: a rare but real surgical emergency. American Journal of Emergency Medicine. 2010; 28(1):118.e5-7.
  3. Singleton AC. Chronic gastric volvulus. Radiology. 1940;34:53-61.
  4. Milne LW, Hunter JJ, Anshus JS, Rosen P. Gastric volvulus: two cases and a review of the literature. Journal of Emergency Medicine. 1994; 12(3):299-306.
  5. Carter R, Brewer LA 3rd, Hinshaw DB. Acute gastric volvulus. A study of 25 cases. American Journal of Surgery. 1980; 140(1):99-106.
  6. Wasselle JA, Norman J. Acute gastric volvulus: pathogenesis, diagnosis, and treatment. American Journal of Gastroenterology. 1993; 88(10):1780-4.
  7. Katkhouda N, Mavor E, Achanta K, Friedlander MH, Grant SW, Essani R, et al. Laparoscopic repair of chronic intrathoracic gastric volvulus. Surgery. 2000; 128(5):784-90.
  8. Cameron AE, Howard ER. Gastric volvulus in childhood. Journal of Pediatric Surgery. 1987; 22(10):944-7.
  9. Woon CY, Chung AY, Low AS, Wong WK. Delayed diagnosis of intermittent mesenteroaxial volvulus of the stomach by computed tomography: a case report. Journal of Medical Case Reports. 2008; 2:343.
  10. Palanivelu C, Rangarajan M, Shetty AR, Senthilkumar R. Laparoscopic suture gastropexy for gastric volvulus: a report of 14 cases. Surgical Endoscopy. 2007; 21(6):863-6.
  11. Tanner NC. Chronic and recurrent volvulus of the stomach with late results of "colonic displacement". American Journal of Surgery. 1968; 115(4):505-15.
  12. Teague WJ, Ackroyd R, Watson DI, Devitt PG. Changing patterns in the management of gastric volvulus over 14 years. British Journal of Surgery. 2000; 87(3):358-61.

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Last updated: 2018-06-22 08:45