Gastric Volvulus (GV), or the twisting of the stomach, is a rare and potentially catastrophic condition where the stomach rotates abnormally by more than 180 degrees. This rotation creates a closed-loop obstruction, which rapidly leads to incarceration, strangulation, and loss of blood supply to the tissue. Acute GV is a life-threatening abdominal emergency requiring immediate medical attention due to the risk of tissue death and perforation.
Defining Gastric Volvulus
Gastric volvulus is classified based on the anatomical axis of rotation. The most common form is organoaxial volvulus, accounting for nearly 60% of cases. Here, the stomach twists around its long axis, connecting the entry point (cardia) and the exit point (pylorus). This rotation causes the greater curvature to move above the lesser curvature, often leading to complete obstruction and a higher chance of strangulation.
The second type is mesenteroaxial volvulus, which occurs when the stomach rotates around its short axis, running from the middle of the lesser curvature to the middle of the greater curvature. In this type, the lower part of the stomach (antrum) rotates anteriorly and superiorly, potentially twisting the stomach’s blood vessels. Mesenteroaxial rotation is less common (approximately 30% of cases) and often presents with intermittent, chronic symptoms because the obstruction is frequently incomplete. A mixed type, involving rotation along both axes, is the rarest form.
Underlying Causes and Risk Factors
The causes of GV are divided into primary and secondary, reflecting whether an underlying anatomical defect is present. Primary, or idiopathic, GV occurs when no obvious underlying condition is identified. It is presumed to be due to abnormal laxity or absence of the stomach’s supporting ligaments. When these ligaments (connecting the stomach to the spleen, diaphragm, liver, and colon) are stretched or missing, the stomach gains excessive mobility, allowing it to twist. Primary GV accounts for about two-thirds of cases in adults.
Secondary GV is directly linked to specific predisposing conditions that allow the stomach to migrate or rotate freely. The most frequent cause in adults is a diaphragmatic defect, such as a large hiatal hernia, especially a paraesophageal hernia. A hiatal hernia permits the stomach to slide or herniate into the chest cavity, displacing it and making it prone to twisting. The stomach can also become vulnerable due to eventration of the diaphragm, where the diaphragm is abnormally thin or paralyzed, allowing the abdominal contents to bulge upward.
Other factors that increase the risk include prior abdominal surgery, which may create internal adhesions that act as a fixed point around which the stomach rotates, or abnormalities of adjacent organs, like an enlarged spleen. GV is more commonly seen in individuals over 50 years old, often in association with these acquired diaphragmatic or ligamentous issues.
Recognizing the Signs
The presentation of acute gastric volvulus is typically sudden and severe, representing a surgical emergency. The classic combination of symptoms is known as Borchardt’s triad, present in up to 70% of acute cases.
Borchardt’s Triad
The first element is the abrupt onset of severe upper abdominal pain, localized to the epigastric region.
The second feature is vomiting followed by violent, unproductive retching, often described as dry heaves. This occurs because the twist completely obstructs the stomach’s outlet, preventing the passage of contents.
The third sign is the difficulty or inability to pass a nasogastric tube into the stomach. This confirms the mechanical obstruction at the stomach’s inlet or outlet.
In cases where the stomach has migrated into the chest cavity, the pain may radiate to the left shoulder, back, or neck, sometimes mimicking a heart attack due to pressure on the diaphragm. If the twisting leads to reduced blood flow, the patient may also show signs of gastrointestinal bleeding, shock, or cardiopulmonary distress. Recognizing this triad signals the immediate need for medical evaluation and intervention.
Emergency Treatment and Prognosis
Treatment for acute gastric volvulus requires immediate surgical intervention to untwist the stomach and secure it in its correct position. The patient is first stabilized through resuscitation, including administering intravenous fluids and attempting to decompress the stomach, though this is often difficult due to the obstruction. The definitive procedure is surgical detorsion, where the twisted stomach is unwound.
Following detorsion, the stomach is fixed to the abdominal wall, a procedure called gastropexy, to prevent recurrence. If a diaphragmatic defect, such as a hiatal hernia, is present, it is repaired simultaneously to eliminate the predisposing cause. If the twisting has caused tissue death (necrosis) or perforation, the affected portion of the stomach must be surgically removed. The prognosis for acute GV is dependent on the speed of diagnosis and treatment; the mortality rate can be as high as 30% to 50% if the stomach has become strangulated or if intervention is significantly delayed.