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.

• Pain

  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]

  Case Report A 14 year old girl presented with history of upper abdominal pain and recurrent non bilious vomiting since last 2 days. Pain has increased in its intensity and diffused to whole abdomen since 6 hours. [casereports.in]

• 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]

• Fever

  Tick-borne Rickettsia rickettsii Rocky Mountain spotted fever Rickettsia conorii Boutonneuse fever Rickettsia japonica Japanese spotted fever Rickettsia sibirica North Asian tick typhus Rickettsia australis Queensland tick typhus Rickettsia honei Flinders [en.wikipedia.org]

  An elevated white blood cell count accompanied by low-grade fever and a hematocrit drop prompted a contrast-enhanced CT scan of the abdomen and pelvis. [sages.org]

  He denied any preceding or current reflux, nausea, vomiting, diarrhea, fevers/chills, dysuria, prior abdominal surgeries or known congenital defects. Andy Kistler On exam he was afebrile and vital signs were stable. He did not appear toxic. [healio.com]

  There was no history of constipation, fever or a prior surgery. On examination there was fullness in upper abdomen but no tenderness. Bowel sounds were normal. Systemic examination was normal. [jpss.eu]

  History Name: Bhori singh Age & sex: 45 yrs ,male Resident :Baroli ,Bharatpur DOA:05/01/2013 Clinical presentation Pain abdomen: last 3 days Abdominal distention: last 3 days Not passing flatus motion: last 2 days No h/o fever No h/o vomiting 3. [slideshare.net]

• Inflammation

  There was significant attenuation of chest inflammation (P < 0.05, P < 0.01), GV (P < 0.05, P < 0.01) and GER (P < 0.05, P < 0.01) in massage treatment groups compared with those in basic treatment groups. [ncbi.nlm.nih.gov]

  Additionally, the abdomen becomes tender as it fills with fluid that accumulates within the bowel lumen and this is followed by inflammation of the peritoneum and shock. [news-medical.net]

  The bacterium also expresses virulence factors such as CagA and PicB which cause stomach mucosal inflammation. The VacA gene encodes for vacuolating cytotoxin, but its mechanism of causing peptic ulcers is unclear. [en.wikipedia.org]

• Anemia

  We present a case of a six years old boy admitted to our department, appearing with asymptomatic anemia, who was incidentally diagnosed with Type II esophageal hiatal hernia. [pablikado.cz]

  degenerative stomach 537.89 Difficulty mechanical, gastroduodenal stoma 537.89 Disease, diseased - see also Syndrome Fenwick's (gastric atrophy) 537.89 Displacement, displaced Fenwick's disease 537.89 Fish hook stomach 537.89 Gangrene, gangrenous (anemia [icd9data.com]

  Iron deficiency anemia or upper gastrointestinal hemorrhage may occur due to esophagitis following reflux. [kjim.org]

• Vomiting

  A 16-month-old female Caucasian child was admitted to our hospital for recurrent postprandial vomiting episodes, which started at 11 months old, associated with failure to thrive. [ncbi.nlm.nih.gov]

  […] pain, varying from vague to severe, or just with feeding difficulties associated to epigastric distention, with or without nausea and vomiting. [jmedicalcasereports.biomedcentral.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]

• Overeating

  She presented with significant weight loss over a period of two years, with nonspecific symptoms of heartburn, occasional mild epigastric pain and anorexia. [ncbi.nlm.nih.gov]

  All the sutures were left in situ over the skin and tightened after deflation of the pneumoperitoneum. Post-operative period was uneventful. [journalofmas.com]

• Abdominal Distension

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

• Hypotension

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

• Arthritis

  Costochondritis and rheumatic diseases (ie, fibromyalgia and rheumatoid arthritis) are common examples. An oncolologic cause like neoplasm or a hematologic cause such as sickle cell disease can have similar presentation. [consultant360.com]

• Fracture

  Furthermore, chest radiographs may identify evidence of underlying anatomic abnormalities that predispose to gastric volvulus, including diaphragmatic eventration/elevated hemidiaphragm and rib fractures that suggest prior thoracoabdominal blunt force [dovepress.com]

• 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]

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.

• Helicobacter Pylori

  pylori Peptic ulcer, MALT lymphoma, Gastric cancer Helicobacter cinaedi Helicobacter cellulitis [en.wikipedia.org]

  “Helicobacter pylori infection: a clinical overview”. 《Digestive and Liver Disease》 40 (8): 619?26. doi:10.1016/j.dld.2008.02.026. PMID 18396114. ↑ Blaser, M. J. (2006). “Who are we? Indigenous microbes and the ecology of human diseases” (PDF). [ko.wikipedia.org]

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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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.
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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.
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