Gastric Volvulus

Etiology

In 10% to 30% of cases, gastric volvulus is considered primary, resulting from laxity and disruption of the stomach's ligamentous attachments (gastrohepatic, gastrocolic, gastrolienal, and gastrophrenic). For most cases, gastric volvulus is caused by a gastric, splenic, or diaphragmatic anatomic disorder, the most common being a diaphragmatic hernia or an abnormality in gastric function. The organoaxial rotation of the stomach, as described by Singleton, is the most common gastric volvulus (two-thirds of cases). It occurs when the stomach rotates around the pylorus and the gastroesophageal (GE) junction. Mesenteroaxial rotation is less common (one-third of cases) and occurs when the stomach rotates longitudinal lines parallel to the gastrohepatic omentum.[3]

Epidemiology

Gastric volvulus occurs in children, usually less than 1 year, and occurs in older adults, those older than 50 years. There does not seem to be a predilection for gastric volvulus for either gender or race. The most common cause of a gastric volvulus in children and adults is a paraesophageal hernia.[4]

Pathophysiology

Gastric volvulus causes a foregut obstruction in patients. It may present either acutely or with intermittent, recurrent, and chronic symptoms. When the stomach twists on itself, there is always a risk of stomach strangulation with necrosis, perforation, and shock. The mortality rate for an acute volvulus can range from 30% to 50%, thus highlighting the importance of early diagnosis and treatment of gastric volvulus.

History and Physical

A patient's clinical presentation depends on the speed of onset, the type of stomach rotation (volvulus), and the completeness of the foregut obstruction. The presentation of an acute gastric volvulus can be quite severe, with acute epigastric abdominal pain associated with severe retching. In 1904, Borchardt described the triad of acute epigastric pain, retching with the inability to vomit, and the difficulty or inability to pass a nasogastric tube. This triad occurs in up to 70% of patients with an acute organoaxial volvulus. The nasogastric tube passes easily in patients with an acute mesenteroaxial volvulus, as the lower esophageal sphincter remains open. The opposite is appreciated with organoaxial volvulus, as the nasogastric tube is more difficult to pass due to the involvement of more proximal structures, including the lower esophageal sphincter, the fundus, or the cardia. Patients who present with chronic, intermittent, and vague signs and symptoms of upper abdominal pain, nausea, dysphagia, early satiety, vomiting, and hiccups may have a chronic partial or intermittent gastric volvulus.

Evaluation

The diagnosis of a gastric volvulus can be suspected with a good history and physical exam; however, diagnosis can be difficult. The diagnosis of a gastric volvulus may be confirmed radiologically when patients are symptomatic. Plain chest x-ray films that are suspicious for a gastric volvulus demonstrate a spherical stomach or a double air-fluid level on upright chest films and the retrocardiac air-fluid level above the diaphragm on lateral chest film. Albas et al described 4 radiologic findings predictive for a gastric volvulus on an upper gastrointestinal (GI) contrast study by showing gastric air-fluid level above the diaphragm, a paucity of distal bowel gas, reversal of the relative position of the greater curvature of the stomach, and a downward pointing pylorus. A barium swallow may be helpful as an adjunct to chest x-ray. Computed tomography (CT) scans of the chest, abdomen, and pelvis can also be diagnostic. CT scan of the chest, abdomen, and pelvis can provide information about the nature of volvulus and other intraabdominal organs that may be involved, thus assisting pre-operative planning.

Treatment / Management

The traditional treatment for a patient presenting with an acute gastric volvulus is an immediate operation that reduces and untwists the volvulus. This remains the gold standard; however, attempted medical management may be useful in patients at very high risk for surgery. Immediate surgical resection is required for necrosis or perforation of the stomach. Simultaneously, the diaphragmatic hernia should be reduced and closed. The stomach is then fixed to the anterior abdominal wall with a suture or by placing a gastrostomy tube. Open surgery, or combining laparoscopic and endoscopic surgical techniques, has good results. Laparoscopy is often less morbid than an open operation when used to repair chronic and intermittent gastric volvulus. Patients who are fit enough to undergo a surgical procedure should proceed to have their chronic gastric volvulus repaired because of the high morbidity and mortality (30% to 50%) associated with strangulated gastric volvulus.[5][6](B3)

Good results have also been reported with conservative treatment of an acute gastric volvulus in elderly patients if they are not presenting in extremis. Conservative treatment has also been used to help patients with intermittent and chronic volvulus. The patient should be kept upright, and a nasogastric tube should be gently inserted to decompress the stomach. The patient should be adequately resuscitated and re-evaluated often. Some high-risk, elderly patients can be treated endoscopically with decompression and reduction of the stomach and placement of a percutaneous gastrostomy tube to gastropexy the stomach to the abdominal wall. Percutaneous gastrostomy placement can be done as an adjunct in ill patients with chronic or intermittent volvulus or who may have other critical issues that need to be handled before definitive surgery, for example, sepsis from another source.

Differential Diagnosis

The differential diagnosis for gastric volvulus is very broad. The following are potential differential diagnoses:

• Gastroesophageal reflux disease
• Peptic ulcer disease
• Esophageal cancer
• Esophageal motility disorders
• Esophageal diverticulum
• Gastric cancer
• Gastroparesis