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.

• Surgical Procedure

  Management of secondary gastric volvulus acute should always be surgery and the choice of surgical procedure for treatment is chosen according to etiology. [ncbi.nlm.nih.gov]

  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. [symptoma.com]

  In our patient, the surgical procedure of gastropexy, both anterior and fundal, without fundoplication was performed. She showed good improvement after surgery, with resolution of symptoms and weight gain. © 2013 S. [karger.com]

  A Ladd surgical procedure is done to treat MV. [news-medical.net]

  Surgical procedure is also sometimes needed in asymptomatic chronic case depending on its etiology. [webview.isho.jp]

• Collapse

  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]

  In theory, positive‐pressure ventilation might preferentially ventilate the normal lung rather than the collapsed lung. [academic.oup.com]

  […] eventration laparoscopic adjustable gastric banding 4 Plain radiograph chest radiograph intrathoracic; upside-down stomach retrocardiac fluid level abdominal radiograph; when performed with the patient upright double air-fluid level large, distended stomach collapsed [radiopaedia.org]

  […] organoaxial and mesenteroaxial volvulus Radiographic Findings • Radiography Abdominal plain films; patient upright – Double air-fluid level – Large, distended stomach; seen as air- and fluid-filled spheric viscus displaced upward and to left – Small bowel collapsed [radiologykey.com]

  Sepsis and cardiovascular collapse can follow a perforation. Treatment for a Twisted Stomach A gastric volvulus may be acute or chronic. Emergency surgery is necessary for an acute gastric volvulus. [healthhype.com]

• Weakness

  It comes into your thorax through a weakness or tear in your diaphragm. Gastric volvulus is also more commonly found in people who have birth defects, also known as congenital abnormalities, of their diaphragm. [mddk.com]

  It is mostly secondary to a diaphragmatic or a paraesophageal hernia. [1], [2], [3] Weak supporting ligaments mainly the gastrocolic and gastrosplenic ligaments or their disruption following upper abdominal surgery allow abnormal mobility of greater curvature [journalofmas.com]

  Perforation where the stomach may tear usually at the necrotic area which is weak. Sepsis and cardiovascular collapse can follow a perforation. Treatment for a Twisted Stomach A gastric volvulus may be acute or chronic. [healthhype.com]

  Causes of Gastric Volvulus Volvulus of the stomach is more common in individuals with birth defects (congenital abnormalities) of their diaphragm; hiatus hernia; too long gastric (stomach) ligaments; no spleen; weak muscles (motor neurone diseases); tumour [abdopain.com]

• Severe Pain

  Sometimes severe pain at the top of left shoulder, this may be due to internal bleeding irritating the diaphragm upon respiration. [en.wikipedia.org]

  Acute gastric volvulus – severe pain just below your breastbone, retching without being able to properly vomit. You may also have breathlessness and swelling of the upper abdomen with the lower abdomen remaining flat and feeling soft. [mddk.com]

  Volvulus causes severe pain and progressive injury to the intestinal wall, with accumulation of gas and fluid in the portion of the bowel obstructed. [1] Ultimately, this can result in necrosis of the affected intestinal wall, acidosis, and death. [marefa.org]

• Trisomy 21

  Case presentation A 50-year-old male patient, with Down syndrome/trisomy 21 derived from a 14/21 Robertsonian translocation, was presented at our hospital who suffered from severe abdominal pain. [surgicalcasereports.springeropen.com]

• Dyspnea

  She complained of dyspnea and significant weight loss (15 kg) over the last 2 years. On admission, blood pressure, heart rate, respiration rate, and body temperature were within normal limits. [acgcasereports.gi.org]

  Myocardial ischemia and aortic dissection are, however, the most worrisome causes of chest pain. 4 The former is usually substernal, radiating to the left arm or jaw along with diaphoresis, nausea, vomiting, dyspnea, and palpitations. [consultant360.com]

  In this video, we show the case of a large paraesophageal hernia in a young male patient aged 40 presenting with dyspnea, thoracic pain and iterative dysphagia. [websurg.com]

  Further symptoms include early satiety, chest pain, dyspnea, and dysphagia. [symptoma.com]

  They may report early satiety, dyspnea, and chest discomfort. Dysphagia may occur if the esophagogastric junction (EGJ) is distorted. [emedicine.medscape.com]

• 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]

  Patients with gastric volvulus can present with either acute or chronic abdominal pain. In addition to abdominal pain, symptoms include chest pain, reflux, nausea/vomiting, hematemesis, dysphagia and bloating. [healio.com]

  On physical exam, he was alert and oriented, and had abdominal pain but no acute distress. Heart and lung exams were normal. [journals.lww.com]

• 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]

• Abdominal Distension

  Immediately after EGD she developed increased severity of pain, vomiting and abdominal distension. [ncbi.nlm.nih.gov]

• Acute Abdomen

  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]

  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]

  It may be diagnosed incidentally on a routine abdominal screening or the patient may present with an acute abdomen due to acute torsion of the splenic pedicle with splenic ischemia/infarction [ 6, 7 ]. [pancreas.imedpub.com]

• Constipation

  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]

  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. [symptoma.com]

  [بحاجة لمصدر] Sigmoid volvulus is particularly common in elderly persons and constipated patients. Patients experience abdominal pain, distension, and absolute constipation. [marefa.org]

  There are no symptoms of intestinal obstruction such as vomiting, constipation, abdominal distension or abdominal pain. She has no other past medical history of note. [websurg.com]

• Heart Disease

  Even in the presence of cardiac risk factors and history of heart disease, acute gastric volvulus should be considered, especially if the patient has a hiatal hernia. [consultant360.com]

  Stomach cancer, coronary heart disease, inflammation of the stomach lining, gallbladder inflammation [1] Treatment Stopping smoking, stopping NSAIDs, stopping alcohol, medications [1] Medication Proton pump inhibitor, H2 blocker, antibiotics [1] [4] [en.wikipedia.org]

• Hypotension

  She underwent laparotomy revealing gangrenous gastric fundus perforation complicated by persistent intraoperative hypotension. [ncbi.nlm.nih.gov]

• Ulcer

  Peptic ulcer disease Other names Peptic ulcer, stomach ulcer, gastric ulcer, duodenal ulcer Deep gastric ulcer Specialty Gastroenterology General surgery Symptoms Upper abdominal pain, belching, vomiting, weight loss, poor appetite [1] Complications Bleeding [en.wikipedia.org]

  Laparoscopy for Perforated Peptic Ulcer (PUP) Since the introduction of PPI treatment, perforated ulcer is decreased, but it still occurs. It is more frequent in men than in women and it has the highest incidence in patients aged between 40 and 60. [websurg.com]

  |Peptic (gastric) ulcer ( Cushing ulcer, Dieulafoy's lesion ) - عسرهضم Dyspepsia - Pyloric stenosis - Achlorhydria - خزل المعدة Gastroparesis - Gastroptosis - Portal hypertensive gastropathy - التوسع الشرياني الهضمي الغاري vascular ectasia - Gastric dumping [marefa.org]

  […] disorder, hemorrhage Duodenal disorder, prolapse Duodenal hemorrhage Duodenal mass Duodenal polyposis Duodenal prolapse Duodenal varices Duodenogastric reflux Efferent loop syndrome Erosive duodenopathy Extrinsic compression of stomach Familial duodenal ulcer [icd9data.com]

  Her medical history included high blood pressure, peptic-ulcer disease, hiatal hernia, and diverticular disease. There was no history of myocardial infarction. Medicines included propranolol, cimetidine, antacids, and a diuretic. [nejm.org]

• Paresis

  Case Report The patient was an 80-year-old male with a history of ischemic cardiopathy (acute heart attack in 2002), chronic atrial fibrillation and a previous ischemic stroke in 2004 with residual paresis of the left side and complex epileptic attacks [ispub.com]

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.

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.

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].

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].

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.

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].

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.

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.

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:

• Abdominal pain in the epigastric or left upper quadrant region
• Some will experience sharp chest pain that moves to the neck, shoulder, arm, or back. (This resembles a heart attack)
• Abdominal distension
• Retching
• Vomiting with blood
• Hiccups

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

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