Diagnosis

Gastric volvulus

Etiology

Cause

• Primary gastric volvulus (40%): [qka]

  1. The stomach is anchored to fixation points that prevent abnormal rotation:

     • Gastrocolic ligament

     • Gastrosplenic ligament

     • Gastrohepatic ligament

     • Gastrosplenic ligaments

     • Esophagogastric junction

     • Pylorus

  2. Agenesis, laxity, or disruption of these ligaments may cause pathologic rotation

• Secondary gastric volvulus: [seh]

  • Diaphragmatic hernia (43%)

  • Gastric neoplasm

  • Intestinal malrotation

  • Spleen, transverse colon, and liver anatomic disorder

Pathophysiology [wbp][4ud][pto]

1. Organoaxial volvulus (60%): rotation about a longitudinal axis formed by a line connecting the cardia and pylorus

   • Complete rotation: often impair gastric blood flow and may cause acute gangrene (5%). Organoaxial volvulus usually has an acute presentation and often is associated with the presence of a large paraesophageal hiatus hernia or eventration of the diaphragm.

2. Mesenteroaxial volvulus (30%): rotation about a vertical axis passing through the middle of the lesser and greater curvatures

   • Partial rotation: may be asymptomatic or cause chronic symptoms. Mesenteroaxial volvulus is often intermittent and incomplete.

3. Combination (10%)

4. Gastric volvulus causes a foregut obstruction -->

Complication [pto]

• Gastric strangulation

• Necrosis and perforation

• Sepsis

Epidemiology

Incidence per 100.000 [eyf][pto][qka][pmk][b2q]

Approach

• Gastroscopy

• Chest x-ray

• Abdominal x-ray with Barium

• Ultrasound abdomen: the position of SMA/SMV may indicate malrotation, peanut sign

• CT thorax/abdomen

Treatment

1. Correction of dehydration and electrolyte imbalance

2. Decompression:

   • Nasogastric tube may return the stomach to its normal position

   • Endoscopic-assisted decompression

3. Endoscopic fixation: Fixation of the stomach with two percutaneous endoscopic gastrostomy tubes; these are removed after adhesions fix the stomach to the anterior abdominal wall. [wbp][seh]

4. Surgery if acute volvulus with a risk of vascular compromise or persistent symptoms:

   • Laparoscopic reduction + diaphragmatic hernia repair [4ud]

   • Laparotomy: open surgical reduction with or without gastropexy [4ud]

     • Diaphragmatic hernia repair

     • Gastropexy

     • Gastropexy with division of the gastrocolic omentum (Tanner's operation)

     • Partial gastrectomy, fundo-antral gastrogastrostomy (Opolzer's operation)

Differential diagnoses

Achalasia, Adhesion, Benign neoplasm of the small intestine, Bezoar, Celiac disease, Cholelithiasis, Colorectal cancer, Diabetic gastroparesis, Diverticulitis, Esophageal cancer, Esophageal diverticula, Esophageal hiatal hernia, Femoral hernia, Gastric cancer, Gastric outlet obstruction, Gastroesophageal reflux disease, Gastrointestinal obstruction, Incisional hernia, Inguinal hernia, Myocardial infarction, Pancreatic cancer, Perforated ulcer, Peutz-Jeghers syndrome, Pyloric stenosis, Small bowel cancer, Ulcer disease, Umbillical hernia, Volvulus