You are in: eMedicine Specialties > Radiology > GASTROINTESTINAL Gastric VolvulusArticle Last Updated: Aug 7, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Jeremy Green, MD, Staff Physician, Department of Radiology, Montefiore Medical Center Jeremy Green is a member of the following medical societies: American College of Radiology Coauthor(s): Marjorie Stein, MD, Clinical Assistant Professor of Radiology, Albert Einstein College of Medicine; Consulting Staff, Department of Radiology, Montefiore Medical Center Editors: Neela Lamki, MD, Professor, Department of Radiology, Sultan Qaboos University, Oman; Adjunct Professor, Department of Radiology, Baylor College of Medicine; Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand; Abraham H Dachman, MD, FACR, Professor, Department of Radiology, The University of Chicago School of Medicine; Director of CT, Department of Radiology, The University of Chicago Hospitals; Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute; Eugene C Lin, MD, Consulting Staff, Department of Radiology, Virginia Mason Medical Center Author and Editor Disclosure Synonyms and related keywords: gastric torsion, closed-loop obstruction, gastric strangulation, gastric rotation, subdiaphragmatic volvulus, primary volvulus, supradiaphragmatic volvulus, secondary volvulus INTRODUCTIONSection 2 of 12
  BackgroundGastric volvulus (Latin volvere, to roll) is rotation of all or part of the stomach by more than 180º, which may lead to a closed-loop obstruction and possible strangulation. Symptoms may range from mild abdominal pain and vomiting, when no or partial outlet obstruction is present, to severe pain and retching, when there is complete obstruction and ischemia. For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles Abdominal Pain in Adults and Barium Swallow . PathophysiologyGastric volvulus is classified on the basis of its location in reference to the diaphragm and on the basis of the axis of rotation. Subdiaphragmatic, or primary, volvulus accounts for approximately one third of cases, and it is not associated with diaphragmatic defects. Supradiaphragmatic, or secondary, volvulus accounts for approximately two thirds of cases, and it is associated with diaphragmatic defects. Predisposing factors occur with this type of volvulus in more than 50% of cases and include paraesophageal hiatal hernias, diaphragmatic eventration, diaphragmatic trauma, diaphragmatic paralysis from phrenic nerve injury, gastric ulcer or neoplasm, extrinsic pressure from enlarged adjacent organs or masses, and abdominal adhesions. Gastric volvulus is also classified on the basis of its axis of rotation. In the more common, organoaxial volvulus (59% of cases), the stomach rotates on its longitudinal axis. This axis is defined as the line connecting the cardia and pylorus. The greater curvature moves from an inferior to a superior position. Compared with the other types of gastric volvulus, organoaxial volvulus is more commonly associated with strangulation. Because of the rich vascular supply of the stomach, strangulation occurs in only 5-28% of cases. In mesenteroaxial volvulus (29% of cases), the stomach rotates about a vertical axis passing through the middle of the greater and lesser curvatures. The pylorus moves anteriorly and superiorly, whereas the greater curvature remains inferior. Mesenteroaxial volvulus is more often seen in young children and is associated with ligamentous laxity but not with diaphragmatic defects. In both of these classifications, the configuration of the stomach may be characterized as upside down. The remaining cases demonstrate features of organoaxial and mesenteroaxial volvulus (2%), or they are unclassified (10%). Mortality/MorbidityThe mortality rate for acute gastric volvulus is reportedly 42-56%. The mortality rate for chronic gastric volvulus is 10-13%. Reported complications include the following:
RaceNo racial predilection is reported. SexGenerally, the prevalence rates are considered equal in males and females. However, at least 1 study shows a female predilection. AgeGastric volvulus occurs in persons of any age, although the incidence peaks in those aged 40-50 years. Approximately 20% of cases occur in infants younger than 1 year. AnatomyThe primary and secondary forms of gastric volvulus are associated with laxity of the supporting structures of the stomach. The gastrophrenic, gastrohepatic, gastrosplenic, and gastrocolic ligaments hold the stomach in place at the esophageal hiatus and pylorus. These ligaments allow significant gastric mobility but normally never permit more than 180º of rotation. Typically, laxity increases with age, and it may be more common in females than in males. In neonates, these ligaments may be absent or abnormally loose, resulting in volvulus. In the older child, gastric distention with air or fluid as a result of pyloric hypertrophy, pyloric stenosis, or air swallowing may cause ligamentous laxity and volvulus. Clinical DetailsThe signs and symptoms of gastric volvulus depend on the condition's type (primary or secondary) and chronicity, as well as the degree of obstruction. Chronic volvulus may be detected incidentally on plain chest radiographs or on upper gastrointestinal (GI) series. Symptoms and signs include the following:
Acute cases represent a surgical emergency. Typical symptoms and signs are described by noting the Borchardt triad:
Preferred ExaminationThe definitive diagnosis of gastric volvulus resides with the radiologist. Typically, the first examination to be performed in the patient with symptoms referable to the chest and/or abdomen is a plain radiograph. Although this is a good examination to start with, the most definitive study is the upper GI barium study. Limitations of TechniquesPlain radiography may demonstrate findings that are indistinguishable from those that are produced by other causes of gastric atony or obstruction. However, the modality is useful for excluding other causes of the patient's symptoms, such as pneumoperitoneum or pneumothorax. Barium study is highly sensitive and specific. However, the diagnosis may be missed in cases of intermittent torsion. Fiberoptic endoscopy has a limited role in the diagnosis of gastric volvulus because the twist precludes passage of the endoscope. Laboratory studies are generally unrewarding, although levels of amylase and alkaline phosphatase may be increased. DIFFERENTIALSSection 3 of 12
Cholecystitis, Acute Duodenum, Ulcers Esophagus, Tear Gastric Ulcer Myocardial Infarct, Acute Pancreatitis, Acute Other Problems to Be ConsideredIn chronic gastric volvulus - Chronic cholecystitis, ischemic heart disease In acute gastric volvulus - Acute gastric dilatation, gastric outlet obstruction, perforated peptic ulcer, ruptured gallbladder RADIOGRAPHSection 4 of 12
FindingsIn mesenteroaxial volvulus, the distended stomach appears spherical on supine images. Two air-fluid levels are visible on the upright film: 1 in the fundus, which is inferior, and 1 in the antrum, which is superior. In addition, the upright image often demonstrates a beak where the esophagogastric junction is seen on normal images. If a nasogastric tube is passed, the esophagogastric junction is seen inferior to its normal location. If barium moves past the esophagogastric junction, the upside-down configuration of the stomach and the degree of obstruction can be documented. Organoaxial volvulus is difficult to diagnose on plain images. The stomach lies horizontally and contains a single air-fluid level on upright views. No characteristic beak is observed. Decreased air is noted within the remaining GI tract. Barium study shows that the esophagogastric junction is lower than normal. Marked gastric dilatation and the slow passage of contrast material past the site of twisting are noted. Degree of ConfidencePlain radiographic findings that are suggestive of gastric volvulus should be confirmed with a barium study. False Positives/NegativesAlthough the classic plain radiographic findings described above are suggestive of volvulus, a false-negative diagnosis may result if the twisted stomach is filled with fluid. A distended, air-filled stomach may result secondary to other causes of gastric obstruction, leading to a false-positive diagnosis. The barium study is highly sensitive and specific for gastric volvulus. It is generally considered to be the criterion standard for diagnosis. However, as stated above, the diagnosis may be missed in cases of intermittent torsion. The upper GI series may show only a paraesophageal hernia or eventration of the diaphragm during a symptom-free interval, leading to a false-negative diagnosis. CT SCANSection 5 of 12
FindingsThe computed tomography (CT) scanning and magnetic resonance imaging (MRI) appearance of gastric volvulus can be variable. The extent of diaphragmatic herniation, the points of torsion, and the final position of the stomach determine the appearance. Degree of ConfidenceCT scanning and MRI are not typically considered to be the diagnostic examinations of choice in patients who are evaluated for gastric volvulus. However, some experts argue that the multiaxial reconstructions that are afforded by helical CT in particular may be preferred to the images obtained with conventional barium study, particularly in the acutely ill patient who is unable to tolerate a fluoroscopic examination. In addition, chronic gastric volvulus is often discovered incidentally in patients undergoing CT scanning for an unrelated condition. In most patients, CT-scan or MRI findings that suggest a gastric volvulus should be confirmed with an upper GI series. False Positives/NegativesWithout torsion, gastric volvulus may be difficult to distinguish from paraesophageal hiatal hernia, and false-positive, as well as false-negative, diagnoses can result. MRISection 6 of 12
FindingsSee CT Scan/Findings. Degree of ConfidenceSee CT Scan/Degree of Confidence. False Positives/NegativesSee CT Scan/False Positives/Negatives. ULTRASOUNDSection 7 of 12
FindingsA study has demonstrated the peanut sign in a case of chronic gastric volvulus. The ultrasonographic features consist of a constricted segment of stomach, with 2 dilated segments located above and below the constricted part, akin to a peanut. Degree of ConfidenceUltrasonography is a noninvasive modality that can be performed on debilitated patients relatively easily and repeatedly; it requires no specific preparation. However, ultrasonography as a technique for the detection of gastric disease (and of gastric volvulus in particular) is still in its infancy. In several case reports, the ultrasonographic evaluation of gastric volvulus shows normal findings. Until more data are available, upper GI series should be used to confirm the diagnosis. NUCLEAR MEDICINESection 8 of 12
FindingsGastric volvulus may be discovered during scintigraphic examination, sometimes incidentally, as the cause of a patient's symptoms. In 1 case report, a technetium-99m pertechnetate Meckel scan obtained to assess chronic GI bleeding in a child demonstrated an intrathoracic stomach with the greater curvature superior to the lesser curvature. Another case report demonstrated similar findings during an iodine-131 whole-body scan in a patient with metastatic thyroid cancer. In each case, upper GI series confirmed an organoaxial volvulus. Degree of ConfidenceScintigraphic evidence of gastric volvulus should be confirmed with an upper GI series. ANGIOGRAPHYSection 9 of 12
FindingsDuring an episode of gastric volvulus, the arteries supplying the stomach are displaced according to the position of the stomach. Typically, the right and left gastroepiploic arteries are displaced high beneath the left hemidiaphragm. The right gastroduodenal artery also is displaced, and the left gastric artery appears to be coiled and shortened. Degree of ConfidenceAngiography is often used in the evaluation of massive or refractory GI hemorrhage. Although it is a rare cause of such hemorrhage, gastric volvulus should be considered. The angiographic appearance is sensitive and specific during an acute episode. INTERVENTIONSection 10 of 12
Reduction of acute gastric volvulus is first attempted with nasogastric decompression. This is often unsuccessful, however, particularly in cases of organoaxial volvulus with obstruction. Surgical goals include reduction, the prevention of recurrence, and the repair of predisposing factors. Specifically, treatment involves anterior gastropexy or gastrostomy in order to fix the stomach in its anatomically correct position or involves partial or total gastrectomy in the setting of necrosis or carcinoma. Diaphragmatic defects may be repaired with fundoplication. Laparoscopic techniques have been used as well. Chronic gastric volvulus may be treated by using the aforementioned surgical techniques. However, in primary cases without diaphragmatic defects, endoscopic reduction with percutaneous endoscopic gastrostomy fixation has been successful. Some authors argue that surgical intervention is necessary in these cases only when endoscopic management fails or when the volvulus recurs. Although radiologic interventions are not commonly used, they are potentially useful interventional strategies. Several authors advocate palliative stenting for obstructions of the gastric outlet in patients who are not candidates for surgery. Under combined fluoroscopic and endoscopic guidance via a perioral route, the self-expanding vascular Wallstent has been placed successfully in patients with malignant or benign gastric outlet obstructions. Although its use with gastric volvulus has not been documented, this intervention may be useful in the setting of obstruction secondary to volvulus. Medical/Legal Pitfalls
MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
Article Last Updated: Aug 7, 2007 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
