Practice Essentials
Gastric volvulus is a rare clinical entity defined as an abnormal rotation of the stomach of more than 180°, which creates a closed-loop obstruction that can result in incarceration and strangulation. [1] It can manifest either 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. (See Presentation.)
Berti first described gastric volvulus in an autopsy of a female patient in 1866. Years later, in 1896, Berg performed the first successful operation for this condition. In 1904, Borchardt described the classic triad associated with gastric volvulus:
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Severe epigastric pain
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Retching without vomiting
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Inability to pass a nasogastric tube
The classification system that has been most frequently used for gastric volvulus, proposed by Singleton, [2] relates to the axis around which the stomach rotates and includes the following three types (see Pathophysiology):
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Organoaxial
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Mesenteroaxial
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Combined
In etiologic terms, gastric volvulus can be classified as either type 1 (idiopathic) or type 2 (congenital or acquired). (See Etiology.)
Because many cases of chronic volvulus are not diagnosed, the incidence and prevalence of gastric volvulus are unknown. (See Epidemiology.)
In general, treatment of an acute gastric volvulus involves emergency surgical repair. In patients who are not surgical candidates, endoscopic reduction may be attempted. In patients who are at high risk for surgery, emergency endoscopic reduction may allow adequate resuscitation and medical optimization before definitive surgical repair. Chronic gastric volvulus may be treated on a nonemergency basis, and surgical treatment increasingly involves a laparoscopic approach. (See Treatment.)
See also Anatomy of the Stomach, Volvulus, Disorders of Rotation/Fixation and Midgut Volvulus, Gallbladder Volvulus, Intestinal Volvulus, Intestinal Malrotation, Sigmoid and Cecal Volvulus, and Omental Torsion.
Pathophysiology
Organoaxial type
In an organoaxial gastric volvulus, the stomach rotates around an axis that connects the esophagogastric junction (EGJ) and the pylorus. The antrum rotates in the opposite direction to the fundus of the stomach.
This is the most common type of gastric volvulus, occurring in approximately 59% of cases, [3] and it is usually associated with diaphragmatic defects. Strangulation and necrosis commonly occur with organoaxial gastric volvulus and have been reported in 5-28% of cases. [4]
Mesenteroaxial type
The mesenteroaxial axis bisects 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. This etiology accounts for approximately 29% of cases of gastric volvulus. [3]
Patients with mesenteroaxial gastric volvulus usually present without diaphragmatic defects and usually have chronic symptoms.
Combined type
The combined type of gastric volvulus is a rare form in which the stomach twists both mesenteroaxially and organoaxially. This type of gastric volvulus makes up the remainder of cases and is usually observed in patients with chronic volvulus. [5]
Etiology
Type 1 (idiopathic)
Idiopathic gastric volvulus makes up 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. Type 1 gastric volvulus is more common in adults but has been reported in children.
Type 2 (congenital or acquired)
Type 2 gastric volvulus 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 et al reviewed the anatomic defects associated with type 2 gastric volvulus in the pediatric population (see Table 1 below). [6]
Table 1. Anatomic Defects Associated With Gastric Volvulus (Open Table in a new window)
Congenital defects |
Diaphragmatic defects: 43% |
Gastric ligaments: 32% |
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Abnormal attachments, adhesions, or bands: 9% |
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Asplenism: 5% |
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Small- and large-bowel malformations: 4% |
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Pyloric stenosis: 2% |
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Colonic distention: 1% |
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Rectal atresia: 1% |
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Complicating gastroesophageal surgery |
— |
Neuromuscular disorders |
Poliomyelitis |
Source: Miller DL, Pasquale MD, Seneca RP. Gastric volvulus in the pediatric population. Arch Surg. Sep 1991;126(9):1146-9. [6] |
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The most common causes of gastric volvulus in adults are diaphragmatic defects (see Table 2 below).
Table 2. Causes of Secondary Gastric Volvulus in Adults (Open Table in a new window)
Diaphragmatic Defects |
Gastroesophageal Surgery |
Neuromuscular Disorder |
Increased Intra-abdominal Pressure |
Conditions Leading to Diaphragmatic Elevation |
Hiatal 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 |
In cases of paraesophageal hernias, the EGJ remains in the abdomen, whereas the stomach ascends adjacent to the esophagus, resulting in an upside-down stomach. Gastric volvulus is the most common complication of paraesophageal hernias.
Gastric volvulus has also been reported to complicate gastroesophageal surgery, neuromuscular disorders, and intra-abdominal tumors. Rarely, it may be a complication of liver transplantation and may be related to ligation of the hepatogastric ligament during the hepatectomy. [7] Gastric volvulus has been reported after laparoscopic left adrenalectomy [8] or laparoscopic adjustable gastric band placement, [9, 10] as well as in relation to eventration of the diaphragm [11] or large-cell neuroendocrine carcinoma in the stomach. [12]
Epidemiology
Males and females are equally affected. About 10-20% of cases occur in children, [13] usually before the age of 1 year, but cases have been reported in children as old as 15 years. [14] Gastric volvulus in children is often secondary to congenital diaphragmatic defects. The condition is uncommon in adults younger than 50 years. [13]
Prognosis
The nonoperative mortality for gastric volvulus is reportedly as high as 80%. [15] Historically, mortality figures in the range of 30-50% have been reported for acute gastric volvulus, with the major cause of death being strangulation, which can lead to necrosis and perforation. [4, 5, 16] As a consequence of advances in diagnosis and management, the mortality from acute gastric volvulus fell to 15-20% and that from chronic gastric volvulus to 0-13%. [15, 17]
Tables
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 distention: 1% |
|
Rectal atresia: 1% |
|
Complicating gastroesophageal surgery |
— |
Neuromuscular disorders |
Poliomyelitis |
Source: Miller DL, Pasquale MD, Seneca RP. Gastric volvulus in the pediatric population. Arch Surg. Sep 1991;126(9):1146-9. [6] |
|
Diaphragmatic Defects |
Gastroesophageal Surgery |
Neuromuscular Disorder |
Increased Intra-abdominal Pressure |
Conditions Leading to Diaphragmatic Elevation |
Hiatal 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 |
