Gastric volvulus

Section: UGI Sub-section: Gastric and Oesophagus

Definition

• Rotation of the stomach > 180° around a fixed axis of rotation

Incidence

• Usually occurs in association with Hiatus hernia
• 20% in infants – 80% in adults
• Ischaemia in up to 30% of acute gastric volvulus

Aetiology

• Ligamentous abnormality (e.g. laxity, disruption) is required to allow rotation
• Other predisposing factors:
  • Stomach abnormalities
    • E.g. Conditions that produce acute/chronic distension
  • Abnormalities of surrounding viscera
    • E.g. Splenomegaly = Laxity of Gastrosplenic ligament
  • Rotation of the stomach to fill an abnormal space
    • E.g. Large H/H, Diaphragmatic Hernia in child

Classification

• Organo-axial (2/3)
  • Rotates on longitudinal axis between GOJ and Pylorus
    • Because GOJ and pylorus are fixed
  • More commonly associated with other defects (e.g. paraoesophageal hernia)
• Mesenterico-axial (1/3)
  • Rotates on horizontal axis between line bisecting lesser and greater curves (“folds on itself’)
  • More common in children/developmental
  • Cardia remains fixed, pylorus moves
  • Usually incomplete rotation
    • Therefore intermittent symptoms

Clinical

• Often chronic condition that may be surprisingly asymptomatic
• Chronic volvulus more common than acute
  • Symptoms may be confused with GB disease, gastritis, or PUD
  • Pain is often episodic with vomiting
• Acute Gastric Volvulus: Borchardt’s triad
  • Severe Epigastric Pain
  • Retching without Vomiting
  • Inability to pass NG tube
• May be profoundly haemodynamically compromised

Pathology

• Stomach usually maintained in normal position by 4 structures:
  • Phreno-oesophageal ligament (fixes the cardia)
  • Lesser omentum
  • Gastrosplenic
  • Greater omentum

Investigations

• CXR
  • May see double fluid bubble
  • Can evaluate positioning of the stomach
  • Consider contrast studies in chronic volvulus
• Endoscopy can be hazardous

Management

• For chronic volvulus:
  • Expectant non-operative management usually advised
    • Esp. Elderly
  • Repair the hernia & perform anterior gastropexy in symptomatic pts
• If Borchardt’s triad is present
• Surgery:
  • Resuscitate
    • IV fluids
    • NGT if able (Don’t push this)
    • Correct electrolyte abnormality
  • Determine if ischaemia
    • Response to resus, Ongoing pain, WCC/CRP, gas on CT in stomach wall or portal venous system
  • Urgent decompression
    • Endoscopy – allows inspection for necrosis and decompression
  • Surgery
    • Can be delayed 2-3 days as staged procedure after decompression and correction of physiological derangements
  • If unable to decompress or concern for ischaemia
    • Lap or open reduction
      • Either hiatus hernia repair
      • Or can pull down stomach, place NG tube, pexy stomach (suture or gastrostomy)
    • If ischaemia and resection required
      • may need 2 stage surgery
        • Resect and place drain + NGT
        • Then return for anastomosis - with UGI surgeon

Prognosis/Natural History

• Risk of strangulation / infarction in asymptomatic pt is low
• Acute symptomatic volvulus left untreated can cause perforation or necrosis