Gastric volvulus is a serious medical condition involving an abnormal twisting of the stomach. This twisting can lead to an obstruction of the digestive tract and potentially compromise the stomach’s blood supply. While rare, understanding this condition is important due to its potential for severe outcomes if not addressed promptly.
Understanding Gastric Volvulus
Gastric volvulus occurs when the stomach rotates on itself by more than 180 degrees, along either its longitudinal or transverse axis. The twisting motion can obstruct the passage of food and fluids, effectively creating a closed-loop obstruction. This obstruction prevents the normal flow of material through the stomach, which can lead to rapid distension. In acute presentations, the condition arises suddenly and can quickly become an urgent situation.
Causes and Classifications
Axis of Rotation
Gastric volvulus is primarily classified by its axis of rotation: organoaxial or mesenteroaxial. Organoaxial volvulus, the more common form, involves the stomach twisting around an axis connecting the esophagus and the pylorus, often displacing the greater curvature above the lesser curvature. Mesenteroaxial volvulus, less common, involves rotation around an axis bisecting the lesser and greater curvatures, causing the antrum to move anteriorly and superiorly. A combined type, where both rotations occur, is also possible but rare.
Onset and Underlying Causes
The condition can present acutely, with sudden and severe symptoms, or chronically, with intermittent and less pronounced discomfort. Gastric volvulus is also categorized as primary (idiopathic) or secondary. Primary cases, accounting for about 10% to 30% of instances, result from laxity or disruption of the stomach’s supporting ligaments. Secondary gastric volvulus is more frequently linked to other anatomical issues, most commonly a diaphragmatic defect, particularly a hiatal hernia. Other contributing factors can include previous abdominal surgery, abnormal adhesions, or conditions affecting gastric function.
Recognizing the Signs
The symptoms of gastric volvulus depend on the speed of onset and the extent of the twisting. Acute gastric volvulus typically presents with severe, sudden epigastric pain. Patients commonly experience unproductive retching or vomiting, along with an inability to pass a nasogastric tube into the stomach. This combination of severe pain, retching without vomiting, and difficulty passing a nasogastric tube is known as Borchardt’s triad, which is observed in up to 70% of acute organoaxial volvulus cases.
Chronic gastric volvulus, by contrast, may manifest with intermittent abdominal pain, early satiety, or general upper abdominal discomfort after meals. Diagnosis typically involves imaging techniques. X-rays often show a distended stomach or air-fluid levels in the upper abdomen or chest. Computed tomography (CT) scans are valuable for confirming the rotation and assessing any associated complications. An upper gastrointestinal series with contrast can also effectively visualize the stomach’s abnormal position.
Treatment Options
Treatment for gastric volvulus generally involves surgical intervention, especially for acute cases. The primary goals of treatment include untwisting the stomach, assessing its viability, and preventing future recurrence. For acute gastric volvulus, immediate surgical correction is often necessary to reduce the twist and restore normal anatomy.
A common surgical procedure performed to prevent recurrence is gastropexy, where the stomach is fixed to the abdominal wall. Laparoscopic approaches are increasingly used for both acute and chronic cases when the patient’s condition allows. In certain situations, particularly for high-risk patients or as a temporary measure, endoscopic detorsion may be attempted to untwist the stomach without open surgery. If a portion of the stomach has experienced tissue death, a partial gastrectomy to remove the affected part may be required.
Potential Complications and Prognosis
If gastric volvulus is not diagnosed and treated promptly, it can lead to severe and life-threatening complications. These include gastric ischemia, where the blood supply to the stomach is reduced, potentially leading to tissue damage. This can progress to gastric necrosis and even perforation. Such complications can result in severe infection and shock. The mortality rate for acute gastric volvulus can range from 30% to 50% if left unaddressed. With timely diagnosis and appropriate surgical intervention, the prognosis significantly improves, with mortality rates decreasing. However, even after successful treatment, there is a possibility of recurrence.