Gastric Volvulus


Background

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. [2Years later, in 1896, Berg performed the first successful operation for this condition. [3In 1904, Borchardt described the classic triad associated with gastric volvulus [4:

  • Severe epigastric pain
  • Retching without vomiting
  • Inability to pass a nasogastric tube

The most frequently used classification system of gastric volvulus, proposed by Singleton, [5 relates to the axis around which the stomach rotates and includes the following three types (see Pathophysiology):

  • Organoaxial
  • Mesenteroaxial
  • Combined

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.)

See also Anatomy of the StomachVolvulusDisorders of Rotation/Fixation and Midgut VolvulusGallbladder VolvulusIntestinal VolvulusIntestinal MalrotationSigmoid 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, [6 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. [7]

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. [6]

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. [8]

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). [9]

Table 1. Anatomic Defects Associated With Gastric Volvulus (Open Table in a new window)

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. [9]

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. [10Gastric volvulus has been reported after laparoscopic left adrenalectomy [11or laparoscopic adjustable gastric band placement, [1213as well as in relation to eventration of the diaphragm [14or large-cell neuroendocrine carcinoma in the stomach. [15]

Epidemiology

Males and females are equally affected. About 10-20% of cases occur in children, [16 usually before the age of 1 year, but cases have been reported in children as old as 15 years. [17 Gastric volvulus in children is often secondary to congenital diaphragmatic defects. The condition is uncommon in adults younger than 50 years. [16]

Prognosis

The nonoperative mortality for gastric volvulus is reportedly as high as 80%. [18Historically, 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. [7819As 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%.


CLINICAL PRESENTATION


History

Gastric volvulus 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.

Acute gastric volvulus

The Borchardt triad (ie, pain, retching, and inability to pass a nasogastric tube) is diagnostic of acute volvulus and reportedly occurs in 70% of cases. [9Carter et al described three additional findings that are suggestive of gastric volvulus, as follows [7:

  • Minimal abdominal findings when the stomach is in the thorax
  • Gas-filled viscus in the lower chest or upper abdomen on chest radiograph
  • Obstruction at the site of the volvulus on an upper gastrointestinal (GI) radiographic series

Hiccups have been reported to be a subtle sign in the clinical diagnosis of gastric volvulus. [21]

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. This condition is often associated with cardiopulmonary compromise from gastric distention and may mimic an acute myocardial infarction.

Progressive distention and nonproductive retching follow the pain. Patients may have upper abdominal distention and tenderness if the stomach remains intra-abdominal; however, if the stomach becomes intrathoracic, there may be minimal abdominal findings.

Occasionally, some patients present with hematemesis [22secondary to mucosal ischemia and sloughing. This can rapidly progress to hypovolemic shock from loss of blood and fluids.

Chronic gastric volvulus

Patients with chronic gastric volvulus typically present with intermittent epigastric pain and abdominal fullness after meals. They may report early satiety, dyspnea, and chest discomfort. Dysphagia may occur if the esophagogastric junction (EGJ) 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.

An upper GI series can be diagnostic during an acute attack.

Physical Examination

Physical examination findings in patients with gastric volvulus can be nonspecific and relate to the chronicity of the volvulus. Epigastric tenderness and distention can suggest gastric volvulus; in cases of stomach necrosis or severe obstruction, peritonitis can be present.

Complications

Strangulation and necrosis are the most feared complications of gastric volvulus; they can be life-threatening and occur most commonly with organoaxial gastric volvulus (5-28% of cases). [78Gastric perforation occurs secondary to ischemia and necrosis and can result in sepsis and cardiovascular collapse; it can also complicate endoscopic reduction.


Diagnostic Considerations

Physical examination findings can often be misleading and nonspecific in patients with gastric volvulus. Secondary to the multiple other more common abdominal conditions that can cause upper abdominal pain, a high index of suspicion, in conjunction with the appropriate imaging studies (see Workup), is often necessary to confirm the diagnosis.

Differential Diagnoses



Approach Considerations

Biochemical tests usually are not diagnostic for gastric volvulus; however, hyperamylasemia and elevated serum alkaline phosphatase (ALP) have been reported. [23There has also been a report of hyperamylasemia in gastric volvulus leading to a missed diagnosis of pancreatitis. [24]

Imaging studies, such as radiography (plain film and barium contrast) and computed tomography (CT), confirm the diagnosis. Findings on upper gastrointestinal (GI) endoscopy may be suggestive of gastric volvulus.

Plain and Contrast Radiography

Chest

On chest radiography, a retrocardiac gas-filled viscus may be seen in cases of intrathoracic stomach, which confirms the diagnosis.

Abdomen

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 [25and a paucity of distal gas. [26In mesenteroaxial volvulus, plain abdominal radiographic findings include a spherical stomach on supine images and two air-fluid levels on erect images, with the antrum positioned superior to the fundus. [8]

Upper gastrointestinal tract

The diagnosis of gastric volvulus is usually based on barium studies, [2728though some authors recommend CT (see below) as the imaging modality of choice. [2930Upper GI contrast radiographic studies (using barium or diatrizoate meglumine–diatrizoate sodium) are sensitive and specific if performed with the stomach in the twisted state [30and may show an upside-down stomach. Contrast studies have been reported to have a diagnostic yield in 81-84% of patients. [19283132]

Computed Tomography

Often performed for an evaluation of acute abdominal pain, CT can offer an immediate diagnosis by showing two bubbles with a transition line. Proponents of CT in the diagnosis of gastric volvulus report several benefits, including the following [303334:

  • Ability to diagnose the condition rapidly on the basis of a few coronal reconstructed images
  • Ability to detect the presence or absence of gastric pneumatosis and free air
  • Ability to detect predisposing factors (eg, diaphragmatic or hiatal hernias)
  • Ability to exclude other abdominal pathology

In a study that included 10 patients with acute gastric volvulus, Millet et al determined the following two findings to be the most sensitive direct signs of gastric volvulus on CT [35:

  • Antropyloric transition point without any abnormality at the transition zone
  • Antrum at the same level as or higher than the fundus

The presence of both CT findings was 100% sensitive and specific for the diagnosis of gastric volvulus. [35]

Endoscopy

Upper GI endoscopy may be helpful in the diagnosis of gastric volvulus. When this procedure reveals distortion of the gastric anatomy with difficulty intubating the stomach or pylorus, it can be highly suggestive of gastric volvulus. [30In the late stage of gastric volvulus, strangulation of the blood supply can result in progressive ischemic ulceration or mucosal fissuring. 


Approach Considerations

In general, the treatment of an acute gastric volvulus remains emergency surgical repair. [37In 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 on a nonemergency basis, and surgical treatment is increasingly being performed via a laparoscopic approach. A review of patients  with chronic gastric volvulus who were managed conservatively reported a high recurrence rate but very few serious complications. [38]

Contraindications for surgical treatment involve conditions or comorbidities in which the patient cannot tolerate general anesthesia. The surgeon should also exercise clinical judgment and make sure that the patient is optimized and resuscitated before the operation.

Some authors have advocated consideration of emergency endoscopic reduction in the setting of acute gastric volvulus in patients who are at high risk for surgery. [39This strategy may allow the patient to be adequately resuscitated and medically optimized before definitive surgical repair.

Resuscitation and Medical Optimization

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 this may be difficult if the esophagogastric junction (EGJ) is obstructed. [26]

Care should be taken in placing the nasogastric tube. Aggressive tube placement may cause perforation; this is especially true in the pediatric population and therefore generally is not advocated. [9]

Surgical Intervention

Emergency surgical intervention is indicated for acute gastric volvulus, which 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 are best accomplished with surgical therapy. Tanner described the surgical options for repair, [40which include the following:

  • Diaphragmatic hernia repair
  • Simple gastropexy
  • Gastropexy with division of the gastrocolic omentum
  • Fundoantral gastrogastrostomy
  • Repair of eventration of the diaphragm

Minimally invasive approaches

A growing number of reports have described 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. [191841424344]

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. No randomized trials have compared open and laparoscopic surgery in the setting of gastric volvulus, but several reports have reported outcomes for laparoscopically treated acute and chronic gastric volvulus that are comparable or superior to the traditional outcomes obtained with open surgery. [191841]

In a case series that included 11 high-operative-risk patients with obstructive gastric volvulus, Yates et al found that laparoscopic reduction of gastric volvulus and anterior abdominal wall sutured gastropexy enabled all 11 patients to remain free of gastric obstructive symptoms and recurrent episodes of volvulus. [45]

Operative details

Patients with signs of acute peritonitis are better explored through a midline incision. In all other cases, initial laparoscopic exploration should be attempted.

The surgical strategy includes the following:

  • 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 an attempt to decrease the rate of reherniation has also been reported [41]

Technical points related to laparoscopic surgery include the following:

  • 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 (eg, laparoscopic antireflux surgery)
  • Keep the pneumoperitoneum pressure lower than normal (10-12 mm Hg) to facilitate easy reduction of hernia contents [18]
  • The stomach is visualized, and its viability is confirmed; when manipulating the stomach, avoid excess traction, which may lead to perforation
  • Dissect and excise the sac, and carefully separate it from the pleura to avoid pneumothorax [18]
  • Use caution when dissecting the right crus because the left gastric vessel may herniate with the stomach across the edge of the crus [18]
  • The stomach is grasped with a nontraumatic grasper and is 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 [1841]

Postoperative care

Gastric decompression is maintained until the return of bowel function. Pulmonary toilet and early ambulation are important postoperative measures.

Endoscopic Treatment

Although the treatment of gastric volvulus is surgical, advances in laparoscopic surgery have also been accompanied by advances in therapeutic endoscopy, with several reports of endoscopic treatment of acute gastric volvulus. [3932464748495051However, the majority of cases describing endoscopic management pertain to chronic gastric volvulus. [32495051]

Endoscopic 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 surgical procedure to be performed on an elective basis and permitting medical optimization before surgery. [393246Failure to reduce the twist or evidence of strangulation necessitates surgery.

After 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. [4951]

Secondary to the high mortality associated with emergency operative repair of acute gastric volvulus and the typical poor clinical picture associated with patients, emergency endoscopic reduction of the acute volvulus is likely to be a growing consideration in the future. [3932A growing number of reports have described the use of a combination of laparoscopy and endoscopy in the treatment of gastric volvulus. [415253In the future, laparoscopy and endoscopy will increasingly be used to treat gastric volvulus.

Complications

Operative complications are similar to those seen in other conditions requiring major abdominal surgery; they vary according to the series and the type of surgical procedure performed.

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. [54 In a study of 138 patients with hiatal hernia, 10 of the 21 patients who had gastric volvulus required emergency surgery; mortality was 40%, and the incidence of major morbidity was also 40%. [55]

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. [19 Palanivelu et al reported that 14 patients who underwent laparoscopic suture gastropexy for gastric volvulus had no perioperative complications or mortality.



Medication Summary

Medications are used in gastric volvulus to treat associated symptoms, most notably pain, nausea, and vomiting. Commonly used pain medications include morphine sulfate and hydromorphone. Commonly used antiemitics include promethazine and ondansetron.

Analgesics

Class Summary

Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and prevents exacerbations in tachycardia and hypertension.

Morphine sulfate (Duramorph, Astramorph, MS Contin, Avinza, Kadian)

Morphine is the drug of choice for narcotic analgesia due to its reliable and predictable effects, safety profile, and ease of reversibility with naloxone. Like fentanyl, morphine sulfate is easily titrated to desired level of pain control.

Morphine sulfate administered IV may be dosed in a number of ways. It is commonly titrated until the desired effect is obtained.

Hydromorphone (Dilaudid)

Hydromorphone is a potent semisynthetic opiate agonist similar in structure to morphine. It is approximately 7-8 times as potent as morphine on mg-to-mg basis, with a shorter or similar duration of action.

Antiemetics

Class Summary

As dopamine antagonists, these agents are effective if nausea and vomiting are prominent features. They also may act as prokinetics to increase gastric motility and enhance absorption.

Promethazine (Phenergan, Phenadoz)

Promethazine is a phenothiazine derivative that possesses antihistaminic, sedative, antimotion sickness, antiemetic, and anticholinergic effects.

Ondansetron (Zofran)

Odansetron is a selective 5-HT3-receptor antagonist that blocks serotonin both peripherally and centrally. It prevents nausea and vomiting, including that associated with emetogenic cancer chemotherapy (eg, high-dose cisplatin) and complete body radiotherapy.