AUTHOR AND EDITOR INFORMATION

Section 1 of 8  

• Authors and Editors
• Introduction
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

INTRODUCTION

Section 2 of 8  

• Authors and Editors
• Introduction
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Gastric volvulus is defined as an abnormal rotation of the stomach of more than 180°, creating a closed loop obstruction that can result in incarceration and strangulation.

History of the Procedure

Berti first described gastric volvulus in 1866; to date, it remains a rare clinical entity. Berg performed the first successful operation on a patient with gastric volvulus in 1896. Borchardt described the classic triad of severe epigastric pain, retching without vomiting, and inability to pass a nasogastric tube in 1904.

Problem

According to the axis around which the stomach rotates, gastric volvulus is classified as follows:

• Organoaxial
• • The stomach rotates around an axis that connects the gastroesophageal junction and the pylorus. The antrum rotates in opposite direction to the fundus of the stomach.
  • This is the most common type in both children and adults and is usually associated with diaphragmatic defects. Strangulation and necrosis commonly occur with this type and have been reported in 5-28% of cases.
• Mesentericoaxial
• • The axis bisects both the lesser and greater curvatures. The antrum rotates anteriorly and superiorly so that the posterior surface of the stomach lies anteriorly. The rotation is usually incomplete and occurs intermittently. Vascular compromise is uncommon.
  • Patients with this type usually present without diaphragmatic defects and usually have chronic symptoms.
• Combined
• • This is a rare form in which the stomach twists both mesentericoaxially and organoaxially.
  • This form is usually observed in patients with chronic volvulus.

Frequency

Because many cases of chronic volvulus are not diagnosed, the incidence and prevalence of gastric volvulus is unknown. Ten to 20% of cases occur in children, usually before age 1 year, but cases have been reported in children up to age 10 years. Gastric volvulus in children is often secondary to congenital diaphragmatic defects. The condition is uncommon in adults younger than 50 years. Males and females are equally affected.

Etiology

According to etiology, gastric volvulus can be classified as either type 1 (idiopathic) or type 2 (congenital or acquired).

• Type 1
• • This type comprises two thirds of cases and is presumably due to abnormal laxity of the gastrosplenic, gastroduodenal, gastrophrenic, and gastrohepatic ligaments. This allows approximation of the cardia and pylorus when the stomach is full, predisposing to volvulus.
  • This type is more common in adults but has been reported in children.
• Type 2
  • This type is found in one third of patients and is usually associated with congenital or acquired abnormalities that result in abnormal mobility of the stomach.
  • Miller and colleagues have reviewed the anatomic defects associated with this type of gastric volvulus, as presented in Table 1.
  • Table 1. Anatomic Defects Associated with Gastric Volvulus

    Congenital defects	Diaphragmatic defects - 43%
    	Gastric ligaments - 32%
    	Abnormal attachments, adhesions, or bands - 9%
    	Asplenism - 5%
    	Small and large bowel malformations - 4%
    	Pyloric stenosis - 2%
    	Colonic distension - 1%
    	Rectal atresia - 1%
    Complicating gastroesophageal surgery	...
    Neuromuscular disorders	Poliomyelitis

  • The most common cause of gastric volvulus in adults is diaphragmatic defects. In cases of paraesophageal hernias, the gastroesophageal junction remains in the abdomen while the stomach ascends adjacent to the esophagus, resulting in an upside-down stomach. Gastric volvulus is the most common complication of paraesophageal hernias. It has also been reported to complicate gastroesophageal surgery, neuromuscular disorders, and intra-abdominal tumors. Rarely, gastric volvulus may be a complication of liver transplant and may be related to ligation of the hepatogastric ligament during the hepatectomy. Table 2 summarizes the causes of secondary gastric volvulus in adults.
  • Table 2. Causes of Secondary Gastric Volvulus in Adults

    Diaphragmatic Defects	Gastroesophageal surgery	Neuromuscular Disorder	Increased Intra-abdominal Pressure	Conditions Leading to Diaphragmatic Elevation
    Hiatus hernia Posttraumatic	Nissen fundoplication Total esophagectomy Highly selective vagotomy Coronary artery bypass graft	Motor neuron disease Poliomyelitis Myotonic dystrophy	Abdominal tumors	Phrenic nerve palsy Left lung resection Intrapleural adhesions

Clinical

Gastric volvulus can manifest as an acute abdominal emergency or as a chronic intermittent problem. The presenting symptoms depend on the degree of twisting and the rapidity of onset.

• Acute gastric volvulus
• • Intra-abdominal gastric volvulus most commonly manifests as the sudden onset of severe epigastric or left upper quadrant pain.
  • Intrathoracic gastric volvulus manifests as sharp chest pain radiating to the left side of the neck, shoulder, arms, and back.
  • It is often associated with cardiopulmonary compromise from gastric distension and may mimic an acute myocardial infarction.
  • Progressive distension and nonproductive retching follow the pain. Patients may have upper abdominal distension and tenderness if the stomach remains intra-abdominal; however, if intrathoracic, there may be minimal abdominal findings.
  • Occasionally, some patients present with hematemesis secondary to mucosal ischemia and sloughing. This can rapidly progress to hypovolemic shock from loss of blood and fluids.
  • The Borchardt triad (pain, retching, and inability to pass a nasogastric tube) is diagnostic of acute volvulus and reportedly occurs in 70% of cases.
• Chronic gastric volvulus
• • Patients typically present with intermittent epigastric pain and abdominal fullness following meals.
  • Patients may report early satiety, dyspnea, and chest discomfort. Dysphagia may occur if the gastroesophageal junction is distorted.
  • Because of the nonspecific nature of the symptoms, however, patients are often investigated for other common disease entities such as cholelithiasis and peptic ulcer disease.
  • Upper GI series can be diagnostic during an acute attack.

WORKUP

Section 3 of 8  

• Authors and Editors
• Introduction
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Imaging Studies

• Chest x-ray: A retrocardiac gas-filled viscus in cases of intrathoracic stomach confirms the diagnosis.
• Plain abdominal radiography reveals a massively distended viscus in the upper abdomen.
• Barium studies may be valuable in chronic volvulus with the stomach lying horizontal or upside down.
• Often performed for an evaluation of acute abdominal pain, a CT scan can offer immediate diagnosis by showing 2 bubbles with a transition line.

TREATMENT

Section 4 of 8  

• Authors and Editors
• Introduction
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Medical therapy

Although the treatment of gastric volvulus is surgical, endoscopic reduction can be attempted in selected patients. Some of the acute and chronic cases have been treated with endoscopic reduction of the volvulus. This can be accomplished by advancing the scope beyond the point of torsion, then rotating it to untwist the stomach. However, because of the chance of gastric perforation, endoscopic reduction should not be attempted in patients who appear clinically or at endoscopy to have vascular compromise. Endoscopic reduction can be attempted in patients with multiple comorbid conditions who are poor candidates for surgery. Failure to reduce the twist or evidence of strangulation necessitates surgery. Percutaneous endoscopic gastrostomy can be performed after reduction of the volvulus to reduce the incidence of recurrence.

Surgical therapy

Emergent surgical intervention is indicated for acute gastric volvulus. With chronic gastric volvulus, surgery is performed to prevent complications.

Preoperative details

Once the diagnosis is confirmed, nasogastric decompression is attempted and the patient is resuscitated.

Intraoperative details

Patients with signs of acute peritonitis are better explored through a midline incision. In all other cases, initial laparoscopic exploration should be attempted.

• Surgical strategy
• • Reduction of the volvulus
  • Assessment of gastric viability with resection of the gangrenous portions by segmental, subtotal, or total gastrectomy
  • Prevention of recurrence by anterior gastropexy, which is most often accomplished with a gastrostomy tub
• The technique of laparoscopic exploration involves the following:
• • Placement of the scope through the umbilicus.
  • The stomach is visualized, and its viability is confirmed.
  • The stomach is grasped with a nontraumatic grasper and is then reduced and reoriented.
  • A gastrostomy tube is placed to provide postoperative decompression and to prevent recurrence.

Postoperative details

Gastric decompression is maintained until the return of bowel function. Pulmonary toilet and early ambulation are important postoperative measures.

COMPLICATIONS

Section 5 of 8  

• Authors and Editors
• Introduction
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Strangulation and necrosis are life threatening and occur most commonly with organoaxial gastric volvulus (5-28% of cases). Gastric perforation occurs secondary to ischemia and necrosis and can result in sepsis and cardiovascular collapse. Perforation can also complicate endoscopic reduction.

OUTCOME AND PROGNOSIS

Section 6 of 8  

• Authors and Editors
• Introduction
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

The nonoperative mortality rate is reportedly as high as 80%. With advances in diagnosis and management, the mortality rate from acute gastric volvulus is now 15-20%; the mortality rate from chronic gastric volvulus ranges from 0-13%.

FUTURE AND CONTROVERSIES

Section 7 of 8  

• Authors and Editors
• Introduction
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

With advances in laparoscopic surgery, most cases of acute and chronic gastric volvulus can now be approached laparoscopically. In the absence of peritonitis, most cases can be adequately treated laparoscopically.

A combined laparoscopic and endoscopic approach has also been used to better assess the intraluminal and intra-abdominal status of the stomach as well as its position before, during, and after fixation.

REFERENCES

Section 8 of 8

• Authors and Editors
• Introduction
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

• Allam M, Piskun G, Fogler R. Laparoscopic treatment of gastric volvulus: a case report. J Laparoendosc Adv Surg Tech A. Apr 1997;7(2):121-5. [Medline].
• Baudet JS, Armengol-Miro JR, Medina C. Percutaneous endoscopic gastrostomy as a treatment for chronic gastric volvulus. Endoscopy. Feb 1997;29(2):147-8. [Medline].
• Beqiri A, VanderKolk WE, Scheeres D. Combined endoscopic and laparoscopic management of chronic gastric volvulus. Gastrointest Endosc. Nov 1997;46(5):450-2. [Medline].
• Berti A. singulare attortigliamento dele' esofago col duodeno seguita da rapida morte. Gazz Med Ital. 1866;9:139.
• Borchardt M. Aus Pathologie und therapie des magenvolvulus. Arch. klin. Chir. 1904;74:243.
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• Chan KL, Saing H. Iatrogenic gastric volvulus during transposition for esophageal atresia: diagnosis and treatment. J Pediatr Surg. Feb 1996;31(2):229-32. [Medline].
• Cozart JC, Clouse RE. Gastric volvulus as a cause of intermittent dysphagia. Dig Dis Sci. May 1998;43(5):1057-60. [Medline].
• Darani A, Mendoza-Sagaon M, Reinberg O. Gastric volvulus in children. J Pediatr Surg. May 2005;40(5):855-8. [Medline].
• Franco A, Vaughan KG, Vukcevic Z. Gastric volvulus as a complication of liver transplant. Pediatr Radiol. Mar 2005;35(3):327-9. [Medline].
• Koger KE, Stone JM. Laparoscopic reduction of acute gastric volvulus. Am Surg. May 1993;59(5):325-8. [Medline].
• Kusunoki M, Hatada T, Ikeuchi H. Gastric volvulus complicating myotonic dystrophy. Hepatogastroenterology. Dec 1992;39(6):586-8. [Medline].
• Kuwano H, Hashizume M, Ohta M. Laparoscopic repair of a paraesophageal hiatal hernia with gastric volvulus. Hepatogastroenterology. Jan-Feb 1998;45(19):303-6. [Medline].
• Miller DL, Pasquale MD, Seneca RP. Gastric volvulus in the pediatric population. Arch Surg. Sep 1991;126(9):1146-9. [Medline].
• Milne LW, Hunter JJ, Anshus JS. Gastric volvulus: two cases and a review of the literature. J Emerg Med. May-Jun 1994;12(3):299-306. [Medline].
• Newman RM, Newman E, Kogan Z. A combined laparoscopic and endoscopic approach to acute primary gastric volvulus. J Laparoendosc Adv Surg Tech A. Jun 1997;7(3):177-81. [Medline].
• Varma JS, Wyatt JP, MacIntyre IM. Gastric volvulus caused by giant ovarian cyst. J R Coll Surg Edinb. Jun 1992;37(3):194. [Medline].
• Yin RL, Nowak TV. Familial occurrence of intrathoracic gastric volvulus. Dig Dis Sci. Nov 1988;33(11):1483-6. [Medline].

Article Last Updated: Aug 15, 2006