gastric volvulus

Gastric volvulus is a specific type of volvulus that occurs when the stomach twists on its mesentery. It should be at least 180° and cause bowel obstruction to be called gastric volvulus. Merely gastric rotation on its root is not considered gastric volvulus.

Epidemiology

Organo-axial volvulus is more common in adults, responsible for 60% of presentations. Mesentero-axial volvulus is more common in children.

Clinical presentation

Patients may present with the classic triad of Borchardt:

  • severe sudden epigastric pain
  • intractable retching without vomiting
  • inability to pass a nasogastric tube

Chronic symptoms are more common in patients with mesentero-axial volvulus.

Pathology

Subtypes
Organo-axial volvulus 
  • more common of the two types in adults (2/3 of cases)
  • commonly occurs in the setting of trauma or para-esophageal hernia
  • stomach is rotated along its long axis (along the cardiopyloric line, which is drawn between the cardia and the pylorus)
  • mirror image of normal anatomy can occur with reversal of the greater and lesser curves 
    • antrum rotates anterosuperiorly
    • fundus rotates posteroinferiorly
  • complete (>180º) present with obstruction or ischemia
  • incomplete rotation (<180º) also called organo-axial position of the stomach, usually asymptomatic
Mesentero-axial volvulus
  • less common in adults, but is more common than organo-axial volvulus in the pediatric population (59% of gastric volvulus)
  • rotation around short axis from the lesser to greater curvature (i.e. perpendicular to the cardiopyloric line)
    • usually incomplete, <180°
  • displacement of antrum above gastro-esophageal junction; stomach appears upside-down with the antrum and pylorus superior to the fundus and proximal body
  • coincides with the axis of mesenteric attachment and is associated with severe obstruction and strangulation
  • less associated with diaphragmatic defect
  • plain films may show an intrathoracic stomach with two air fluid levels
Associations

​Radiographic features

Plain radiograph
  • chest radiograph
    • intrathoracic; upside-down stomach
      • mediastinal or retrocardiac air-fluid level
  • abdominal radiograph; when performed with the patient upright
    • unexpected location of the gastric bubble 
    • double air-fluid level
    • large, distended stomach
    • collapsed small bowel
Fluoroscopy
Upper GI
  • distended stomach in left upper quadrant extending into thorax
  • inversion of stomach
  • volvulus with >180° twist causes luminal obstruction
  • incomplete or absent entrance of contrast material into and/or out of stomach is indicative of acute obstructive volvulus
  • "beaking" may be demonstrated at point of twist
  • mesenteroaxial: antrum and pylorus lie above gastric fundus
CT

The appearance depends on points of torsion, extent of gastric herniation, and final positioning of stomach:

  • distended stomach with antropyloric transition point, located at the level of or superior to the fundus
  • linear septum may be visible within the gastric lumen which corresponds to the site of torsion
  • entire stomach may be herniated (type IV paraesophageal hernia (PEH)) or only part of it (type III PEH)
    • both can result in
      • volvulus
      • obstruction
      • ischemia
    • ischemia seen as lack of contrast enhancement of gastric wall, with or without pneumatosis

Treatment and prognosis

Surgical repair, including stomach detorsion and gastropexy, is the main treatment modality for gastric volvulus. Detorsion may be performed open or laparoscopically. If the stomach is strangulated or necrotic, gastric resection may be required.

​Differential diagnosis