Gastric volvulus is a rare clinical entity defined as an abnormal rotation of the stomach of more than 180°, creating a closed loop obstruction that can result in incarceration and strangulation.
Berti first described gastric volvulus in a female autopsy patient in 1866.[1] Years later, in 1896, Berg performed the first successful operation for gastric volvulus.[2] The classic triad associated with gastric volvulus of severe epigastric pain, retching without vomiting, and inability to pass a nasogastric tube was described by Borchardt in 1904.[3]
The most frequently used classification system of gastric volvulus, proposed by Singleton,[4] relates to the axis around which the stomach rotates and 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 of gastric volvulus occurring in approximately 59% of cases,[5] and is usually associated with diaphragmatic defects. Strangulation and necrosis commonly occur with this type and have been reported in 5-28% of cases.[6]
Mesentericoaxial
The 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 comprises approximately 29% of cases.[5]
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 mesentericoaxially and organoaxially.
Combined gastric volvulus makes up the remainder of cases and is usually observed in patients with chronic volvulus.[7]
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,[8] usually before age 1 year, but cases have been reported in children up to age 15 years.[9] Gastric volvulus in children is often secondary to congenital diaphragmatic defects. The condition is uncommon in adults younger than 50 years.[8] Males and females are equally affected.
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 type 2 gastric volvulus in the pediatric population,[10] as presented in Table 1.
Table 1. Anatomic Defects Associated with Gastric Volvulus[10]
View Table
See Table
The most common causes of gastric volvulus in adults are 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.[11]
Gastric volvulus after laparoscopic left adrenalectomy[12] or laparoscopic adjustable gastric band placement,[13] or related to eventration of the diaphragm[14] or to a large-cell neuroendocrine carcinoma in the stomach,[15] have been reported. Table 2 summarizes the causes of secondary gastric volvulus in adults.
Table 2. Causes of Secondary Gastric Volvulus in Adults
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.[10]
Carter described 3 additional findings that are suggestive of gastric volvulus including minimal abdominal findings when the stomach is in the thorax, gas-filled viscus in the lower chest or upper abdomen on chest radiograph, and obstruction at the site of the volvulus on upper GI series.[6]
Hiccups have been reported to be a subtle sign in the clinical diagnosis of gastric volvulus.[16]
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.
In general, the treatment of an acute gastric volvulus remains emergent surgical repair. In patients who are not surgical candidates (secondary to comorbidities or an inability to tolerate anesthesia), endoscopic reduction may be attempted.
Chronic gastric volvulus may be treated nonemergently, and surgical treatment is increasingly being performed using a laparoscopic approach.
Recently, a review of patients managed conservatively with chronic gastric volvulus were reported to have a high recurrence rate but very few serious complications.[17]
Contraindications for surgical treatment involve conditions or comorbidities in which the patient cannot tolerate general anesthesia. The surgeon should also use clinical judgment and make sure the patient is optimized and resuscitated prior to the operation.
Some have advocated consideration of emergent endoscopic reduction in the setting of acute gastric volvulus in patients who are high risk for surgery.[18] This strategy may allow the patient to be adequately resuscitated and medically optimized prior to definitive surgical repair.
Biochemical tests are usually not diagnostic; however, hyperamylasemia and elevated serum alkaline phosphatase have been reported.[19] There has also been a report of hyperamylasemia in gastric volvulus leading to a missed diagnosis of pancreatitis.[20]
Demonstrated through chest radiography, 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. In organoaxial volvulus, plain films may show a horizontally oriented stomach with a single air fluid level[21] and a paucity of distal gas.[22] In mesenteroaxial volvulus, plain abdominal radiographic findings include a spherical stomach on supine images and 2 air-fluid levels on erect images, with the antrum positioned superior to the fundus.[7]
The diagnosis of gastric volvulus is usually based on barium studies[23, 24] ; however, some authors recommend computed tomography (CT) scanning as the imaging modality of choice.[25, 26] Upper GI contrast studies (using barium or gastrograffin) are sensitive and specific if performed with the stomach in the "twisted" state[26] and may show an upside-down stomach. Contrast studies have been reported to have a diagnostic yield in 81-84% of patients.[24, 27, 28, 29]
Often performed for an evaluation of acute abdominal pain, a CT scan can offer immediate diagnosis by showing 2 bubbles with a transition line. Proponents of CT scanning in the diagnosis of gastric volvulus report several benefits, including the ability to rapidly diagnose the condition based on a few coronal reconstructed images, the ability to detect the presence or abscess of gastric pneumatosis and free air, the detection of predisposing factors (ie diaphragmatic or hiatal hernias), and the exclusion of other abdominal pathology.[26, 30]
Upper GI endoscopy showing distortion of the gastric anatomy with difficulty intubating the stomach or pylorus can be highly suggestive of gastric volvulus.[26] Late stage of gastric volvulus with strangulation of the blood supply can result in progressive ischemic ulceration or mucosal fissuring.[31]
Although the treatment of gastric volvulus is surgical, endoscopic reduction can be attempted in selected patients. There are some reports of endoscopic reduction in acute gastric volvulus,[18, 32, 33, 34] but the majority of cases describing endoscopic management pertain to chronic gastric volvulus.[29, 35, 36, 37] Such treatment can be accomplished by advancing the scope beyond the point of torsion and 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 ill or are found to have vascular compromise during endoscopy.
Endoscopic reduction can be attempted in patients with multiple comorbid conditions who are poor candidates for surgery. One potential benefit of endoscopic reduction is that it may act as a temporizing measure in chronic and acute gastric volvulus, allowing the surgery to be performed on an elective basis and to allow medical optimization prior to surgery.[18, 29, 32] Failure to reduce the twist or evidence of strangulation necessitates surgery. Following endoscopic reduction, the use of single or double percutaneous endoscopic gastrostomy tube placement in an attempt to decrease the incidence of recurrence has been reported.[35, 37]
Emergent surgical intervention is indicated for acute gastric volvulus and is still considered a surgical emergency by many surgeons. With chronic gastric volvulus, surgery is performed to prevent complications.
The principles associated with the treatment of gastric volvulus include decompression, reduction, and prevention of recurrence, which is best accomplished with surgical therapy.
Tanner described the surgical options for repair, including diaphragmatic hernia repair, simple gastropexy, gastropexy with division of the gastrocolic omentum, partial gastrectomy, fundoantral gastrogastrostomy, and repair of eventration of the diaphragm.[38]
There have been increased reports of the use of minimally invasive techniques, such as laparoscopy, for the treatment of gastric volvulus. These have the potential to decrease the morbidity associated with the open procedures.[28, 39, 40, 41]
Once the diagnosis of gastric volvulus is confirmed, the patient is resuscitated, medically optimized, and prepared for the operating room. Analgesics and antiemetics should be initiated. In adults, early gastric decompression with nasogastric tube placement is advocated but may be difficult if the gastroesophageal junction is obstructed.[22] Care should be taken when placing the nasogastric tube, as aggressive placement may cause perforation; this is especially true in the pediatric population and therefore is generally not advocated.[10]
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 tube or suture gastropexy
A fundoplication can be added to the procedure if there is an indication of preoperative reflux. Fundoplication in the attempt to decrease the rate of reherniation has also been reported.[40]
Technical points related to the laparoscopic approach include:
The surgeon's experience and comfort level with open and closed techniques should be used to determine the means of safe abdominal access.
Trocars must be placed high on the abdominal wall to allow instruments to reach into the chest. In general, the trocar strategy will be similar to that used for other foregut operations, such as in laparoscopic antireflux surgery.
Keep the pneumoperitoneum pressure lower than normal (10-12 mmHg) to facilitate easy reduction of hernia contents.[39]
The stomach is visualized, and its viability is confirmed. When manipulating the stomach, avoid excess traction, as this may lead to perforation.
Dissect and excise the sac, and carefully separate it from the pleura to avoid pneumothorax.[39]
Use caution when dissecting the right crus, as the left gastric vessel may herniate with the stomach across the edge of the crus.[39]
The stomach is grasped with a nontraumatic grasper and is then reduced and reoriented. Repair of the hiatal hernia is then performed, with fixation of the stomach below the diaphragm.
Gastropexy with a gastrostomy tube is typically done to provide postoperative decompression, allow access for enteral feeding, and prevent recurrence.[39, 40]
Strangulation and necrosis are the most feared complications of gastric volvulus; they can be a life threatening and occur most commonly with organoaxial gastric volvulus (5-28% of cases).[6, 7] Gastric perforation occurs secondary to ischemia and necrosis and can result in sepsis and cardiovascular collapse. Perforation can also complicate endoscopic reduction.
Operative complications are similar to those seen in other conditions requiring major abdominal surgery; they range according to the series and type of surgery. Carlson et al performed a transabdominal open repair of intrathoracic chronic gastric volvulus in 44 patients, reporting a complication rate of 38%, including splenic injuries and wound complications, such as infection and dehiscence.[42] Haas et al reported on 138 patients with hiatal hernia, of which 21 had gastric volvulus. Ten of these 21 patients required emergent surgery.[43] The authors reported a 40% mortality rate and a 40% major morbidity rate.
Teague et al reported no major complications and no mortality in 36 patients, 29 of whom presented acutely with hiatal hernia and 13 of whom underwent laparoscopic repair.[28] Palanivelu et al reported on 14 patients who underwent laparoscopic suture gastropexy for gastric volvulus, reporting no perioperative complications or mortality.[39]
The nonoperative mortality rate for gastric volvulus is reportedly as high as 80%.[39] Historically, mortality rates of 30-50% have been reported for acute volvulus, with the major cause of death being strangulation, which can lead to necrosis and perforation.[6, 7, 28] With advances in diagnosis and management, the mortality rate from acute gastric volvulus is now 15-20% and for chronic gastric volvulus is 0-13%.[39, 44]
With advances in laparoscopic surgery, most cases of acute and chronic gastric volvulus can now be approached laparoscopically. In the absence of peritonitis or an unstable patient, most cases can be adequately treated in this way. There have been no randomized trials comparing open and laparoscopic surgery in the setting of gastric volvulus, but there have been several reports showing comparable or improved outcomes for acute and chronic gastric volvulus, compared with the traditional outcomes obtained with open surgery.[28, 39, 40]
Along with the advances in laparoscopic surgery, there have also been advances in therapeutic endoscopy, with several reports of endoscopic treatment of acute gastric volvulus.[18, 29, 32, 33, 34, 35, 36, 37] Increasingly, there have been reports of combined laparoscopic and endoscopic procedures in the treatment of gastric volvulus.[40, 45, 46]
In the future, laparoscopy and endoscopy will increasingly be used to treat gastric volvulus. Secondary to the high mortality associated with emergent operative repair of acute gastric volvulus and the typical poor clinical picture associated with patients, future considerations for treatment include emergent endoscopic reduction of the volvulus, allowing resuscitation and medical optimization prior to definitive operative repair.[18, 29]
William W Hope, MD, Assistant Professor of Surgery, University of North Carolina at Chapel Hill School of Medicine; Director of Surgical Education, Department of Surgery, New Hanover Regional Medical Center/South East Area Health Education Center
Disclosure: Nothing to disclose.
Coauthor(s)
Mohamed Akoad, MD, Liver Transplant Surgeon, Division of Hepatobiliary and Liver Transplantation, Department of Surgery, Veterans Administration Pittsburgh Healthcare System
Disclosure: Nothing to disclose.
Richard W Golub, MD, FACS, Consulting Surgeon, Sarasota Memorial Hospital and Doctors Hospital; Consulting Surgeon, Intercoastal Medical Group
Disclosure: Nothing to disclose.
Specialty Editors
Juan B Ochoa, MD, Assistant Professor, Department of Surgery, University of Pittsburgh; Medical and Scientific Director, HCN, Nestle Healthcare Nutrition
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Medscape Salary Employment
David L Morris, MD, PhD, FRACS, Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia
Disclosure: RFA Medical None Director; MRC Biotec None Director
Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Disclosure: Nothing to disclose.
Chief Editor
John Geibel, MD, DSc, MA, Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital
Levine ML, Gelberg B. Gastric mucosal disruption (fissuring) as a sign of impending perforation in a patient with gastric volvulus. Gastrointest Endosc. 1993;39:214-215.
Haas O, Rat P, Christophe M, et al. Surgical results of intrathoracic gastric volvulus complicating hiatal hernia. Br. J. Surg. 1990;77:1379.
Katkhouda N, Mavor E, Achanta K, Friedlander MH, Grant SW, Essani R, et al. Laparoscopic repair of chronic intrathoracic gastric volvulus. Surgery. 2000;5:784-790.
