Gastric Volvulus

A disorder in which the stomach twists so as to turn on itself.

This relatively rare condition is more common in elderly persons, in whom the ligaments supporting the stomach are more relaxed than in younger persons. The most common type of gastric volvulus, organoaxial volvulus, involves a rotation of the stomach on its longitudinal axis (from cardia to pylorus). The less common type, mesenteroaxial volvulus, involves a rotation of the stomach on its vertical axis passing through the center of the lesser and greater curvatures. A complete twist of the stomach can result in strangulation of the blood supply, which can lead to gangrene.

Symptoms and Signs

Acute volvulus causes sudden, severe pain localized to the upper abdomen or chest. The upper abdomen can become markedly distended, whereas the lower abdomen remains undistended and soft. Persistent retching with little or no vomitus is common. In complete volvulus, a nasogastric tube cannot be passed. The combination of upper abdominal pain and distention, an inability to vomit, and an impediment to nasogastric tube insertion is known as Borchardt's triad. Chest pain may radiate down the arms and neck and is often accompanied by dyspnea.

Chronic, intermittent gastric volvulus causes mild and nonspecific symptoms, such as epigastric discomfort, heartburn, abdominal fullness or bloating, and borborygmi, especially after meals. Because this is an unusual disorder, these nonspecific symptoms may result in this disorder being underdiagnosed.

Diagnosis and Treatment

Volvulus is usually diagnosed by a plain or contrast x-ray of the abdomen. X-ray of organoaxial volvulus often shows an "upside-down stomach" and double air-fluid levels (fundus and antrum).

The mortality rate is about 15 to 20%. It increases to 40% for cases that require emergency surgery and to about 60% for cases involving strangulation. Treatment is always surgical. In cases of acute strangulation with ischemia or gangrene, or when tube decompression cannot be performed, emergency surgery is necessary. Endoscopic reduction can be used to treat some cases, but it should be considered a temporary measure and is contraindicated in patients who appear to have vascular compromise.