Gastric volvulus is an abnormal rotation of the stomach that partially or completely twists it on itself, cutting off the normal flow of food and sometimes choking off its blood supply. It is rare but genuinely dangerous: if an acute case goes untreated, the mortality rate runs between 42% and 56%, driven by the risk of the stomach wall losing blood flow and dying (ischemia and necrosis) or perforating.1ACS Case Reviews. Perforated Gastric Volvulus in a Patient with Prior Surgery for Hirschsprung’s Disease The condition was first described in an autopsy in 1866, and much of what clinicians know about it still comes from individual case reports and small surgical series rather than large trials, which makes this a corner of medicine where awareness and quick recognition matter more than usual.
How the Stomach Twists
The stomach is anchored inside the abdomen by a set of ligaments and folds of tissue that hold it in roughly the right position. When those attachments are weakened, absent, or displaced by another problem, the stomach can rotate around one of two axes. The type of rotation determines what gets kinked and how the patient presents.
In organoaxial volvulus, the stomach flips along its long axis, the line that runs from the junction with the esophagus down to the pylorus (the outlet into the small intestine). Think of the stomach rotating like a log rolling in water. This is the more common type in adults and is frequently associated with a large hiatal hernia that pulls part of the stomach up through the diaphragm into the chest.2PubMed Central. Gastric Volvulus as a Complication of Giant Hiatal Hernia: A Case Report and Literature Review
In mesenteroaxial volvulus, the stomach rotates around a short axis that runs from the middle of the lesser curvature to the middle of the greater curvature, roughly side to side. This type is less common overall but shows up more often in children.3PubMed Central. Wandering spleen, gastric and pancreatic volvulus and right-sided descending and sigmoid colon A combined or unclassifiable twist can also occur, though it is uncommon.
The degree of rotation matters as much as the direction. A partial twist may cause intermittent symptoms that come and go for months or years. A complete twist, especially one exceeding 180 degrees, can fully obstruct the stomach and strangulate its blood supply within hours.
What Causes It
Most cases in adults trace back to a structural problem that loosens or displaces the stomach’s normal anchoring. By far the most common culprit is a large (sometimes called “giant”) hiatal hernia, in which a wide opening in the diaphragm allows part or all of the stomach to slide up into the chest cavity. Once up there, the stomach has far more room to rotate than it does in the abdomen, and the shift in position can create the twisting force that initiates a volvulus.4Diseases of the Esophagus. V-08. Untwisting the Problem: Robotic-Assisted Management of an Obstructive Gastric Volvulus and Giant Hiatal Hernia
Less often, a volvulus develops because the peritoneal ligaments that strap the stomach, spleen, and colon in place are naturally lax or absent. This is the mechanism behind cases linked to a “wandering spleen,” a condition in which the spleen drifts from its usual spot because the ligaments that normally tether it are too loose. The same ligament problem can let the stomach rotate freely.5PubMed Central. Pancreatic volvulus with wandering spleen and gastric volvulus: an unusual triad for acute abdomen in a surgical emergency Other structural triggers include diaphragmatic defects (congenital or post-traumatic), adhesions from prior abdominal surgery, and masses or tumors that push the stomach out of position.
After Bariatric Surgery
A growing number of case reports describe gastric volvulus developing after weight-loss operations, particularly laparoscopic sleeve gastrectomy. During a sleeve procedure, the greater omentum (a fatty apron of tissue attached to the stomach) is detached, and the stomach is stapled into a narrow tube. That process removes several natural tethering points. Once a patient loses a large amount of weight and intra-abdominal fat shrinks, the sleeved stomach can shift and twist.6PubMed Central. Gastric volvulus after laparoscopic sleeve gastrectomy managed by conversion to Roux-en-Y gastric bypass: A case report and literature review Asymmetric stapling of the front and back walls of the stomach can also create a kink point that predisposes to rotation.7PubMed Central. A Rare Case of Gastric Volvulus Post Laparoscopic Gastric Greater Curvature Plication In some cases, the entire sleeved stomach has migrated up into the chest cavity and twisted there.8Journal of Surgical Case Reports. Intrathoracic sleeve gastrectomy migration with gastric volvulus treated with laparoscopic repair and conversion to gastric bypass These remain individual case reports rather than a common complication, but awareness among bariatric surgeons has been increasing.
Pediatric Causes
In children, gastric volvulus is rare but not unheard of. A review of published cases from 1929 through 2007 identified 581 pediatric cases in the English-language literature, split between 252 acute and 329 chronic presentations.9American Academy of Pediatrics (Pediatrics). Gastric Volvulus in Infants and Children In children, the underlying cause is often a congenital defect involving adjacent organs or diaphragmatic abnormalities, rather than a hiatal hernia. Chronic volvulus in infants under one year typically shows up as feeding difficulties, vomiting, and failure to thrive, symptoms that can be mistaken for reflux or milk allergy for a long time before the real problem is identified.
Recognizing the Signs
The classic warning signs of acute gastric volvulus are grouped under the name Borchardt’s triad: severe pain in the upper abdomen or lower chest, forceful retching that produces little or no vomit (because the twisted stomach traps its contents), and the inability to pass a tube through the nose into the stomach. This triad has been reported in roughly 70% of acute cases.10Radiology Case Reports. A case report of gastric volvulus, a rare cause of acute abdomen When all three elements are present, gastric volvulus should immediately be at the top of the list of possible diagnoses.11PubMed Central. Gastric volvulus, Borchardt’s Triad, and Endoscopy: A Rare Twist
The trouble is that not every case announces itself so neatly. Symptoms of gastric volvulus in general can be nonspecific, mimicking a heart attack, gallbladder disease, or a bowel obstruction lower in the gastrointestinal tract. Pain and nausea with vomiting are the most common complaints but are hardly unique to this condition.12Radiographics. Volvulus of the gastrointestinal tract: appearances at multimodality imaging In elderly patients, the presentation may be muted, with confusion or hemodynamic instability arriving before the classic triad is obvious.
Chronic and Intermittent Gastric Volvulus
Not every gastric volvulus is an emergency. In chronic or intermittent cases, the stomach partially twists and then untwists on its own, producing mild, vague symptoms that recur over weeks or months. Patients often describe bloating, a feeling of fullness after eating, difficulty swallowing, heartburn, or episodes of abdominal pain that are relieved by vomiting.13Open Journal of Gastroenterology. Interesting and unusual cases of chronic abdominal pain-intermittent gastric volvulus One reported pattern involves a “ball-rolling” sensation in the abdomen after eating, which is an unusual symptom but suggestive when it occurs.
Because the symptoms of chronic volvulus overlap with common conditions like acid reflux and functional dyspepsia, a substantial number of cases are missed or misdiagnosed for months. In one retrospective review, the individual symptoms of chronic gastric volvulus, including difficulty swallowing, upper abdominal pain, and chest pain, each showed up only about 29% of the time on their own, making any single symptom unreliable as a diagnostic flag.10Radiology Case Reports. A case report of gastric volvulus, a rare cause of acute abdomen The risk with chronic volvulus is that a partial twist can progress to a full twist at any time, converting a nuisance into an emergency without warning.
How It Is Diagnosed
Imaging is what confirms the diagnosis. A CT scan of the abdomen is the workhorse in most emergency departments. Two CT findings have proven especially reliable: a transition point at the junction between the body and the outlet of the stomach (without any mass or lesion at that point) and the lower part of the stomach sitting at the same level as or higher than the upper part. When both of these signs are present together, one study found they had 100% sensitivity and specificity for diagnosing gastric volvulus.14PubMed. Computed tomography findings of acute gastric volvulus
An upper gastrointestinal barium study (where you swallow contrast liquid while X-rays are taken) can also demonstrate the classic twist, and it was the traditional diagnostic method before CT became widespread.15PubMed. Radiological features of acute gastric volvulus in adult patients In practice, CT has largely replaced barium swallow in acute settings because it is faster and also shows complications like ischemia, perforation, or the presence of a hernia that may be driving the volvulus. Plain X-rays of the chest or abdomen sometimes raise suspicion when they show a massively dilated stomach or a stomach sitting in the chest, but they are not definitive.
What Happens If Blood Supply Is Lost
The stomach has a rich blood supply from multiple arterial sources, which makes it relatively resistant to ischemia compared with other segments of the gastrointestinal tract. Research has shown that both the arterial inflow and venous drainage typically need to be compromised simultaneously before the stomach wall starts to die.16Oxford Academic. Gastric necrosis secondary to gastric volvulus in a paraesophageal hernia: a case report A tight volvulus can do exactly that by kinking the vessels on both sides. Once ischemia sets in, the wall weakens, perforation becomes possible, and the mortality rate climbs steeply. This is why speed matters: the window between a twisted-but-viable stomach and an irreversibly damaged one can be measured in hours.
Emergency and Initial Treatment
Acute gastric volvulus is treated as a surgical emergency. The initial steps focus on stabilizing the patient with intravenous fluids and correcting any electrolyte problems caused by vomiting or obstruction. If perforation or ischemia is suspected, broad-spectrum antibiotics are started early.17IntechOpen. Gastric Volvulus
In many cases, the first therapeutic move is an urgent upper endoscopy. A gastroenterologist passes a flexible scope into the stomach, which serves two purposes at once: it allows direct inspection of the stomach lining for signs of ischemia or necrosis, and the scope itself can sometimes physically push the stomach back into its correct position (a maneuver called endoscopic reduction). A nasogastric tube is placed at the same time to decompress the stomach and relieve trapped gas and fluid.18PubMed Central. Acute Mesentero-Axial Gastric Volvulus in the Setting of a Paraesophageal Hernia: A Rare Case Report Successful reduction through these steps can convert a dire emergency into a situation where definitive surgery can be planned more safely within the next day or two, rather than performed in the middle of the night on an unstable patient.
Definitive Surgical Repair
Reducing the twist is only half the job. Without addressing the underlying cause, the stomach will likely twist again. The definitive treatment almost always involves surgery with several goals: untwist the stomach, fix whatever structural problem allowed the rotation, and anchor the stomach so it stays put.
If a large hiatal hernia is the culprit, the surgical repair includes pulling the stomach back down into the abdomen, excising the hernia sac, and closing the widened opening in the diaphragm (reapproximation of the diaphragmatic crura). A fundoplication, a wrap of the top of the stomach around the lower esophagus, is often added to prevent reflux. The stomach is then tacked to the front abdominal wall (gastropexy) to prevent it from rotating again, sometimes by placing a gastrostomy tube through the skin into the stomach, which physically tethers it in place while the surgical site heals.19PubMed Central. Laparoscopic repair of gastric volvulus
These operations are increasingly performed laparoscopically (through small incisions using a camera), which generally means a shorter hospital stay and faster recovery than open surgery. In cases where the volvulus follows a bariatric procedure like sleeve gastrectomy, conversion to a Roux-en-Y gastric bypass has been used as the definitive fix, because it completely reconfigures the anatomy and removes the conditions that let the sleeved stomach twist.6PubMed Central. Gastric volvulus after laparoscopic sleeve gastrectomy managed by conversion to Roux-en-Y gastric bypass: A case report and literature review
When Surgery Is Not an Option
For elderly or medically frail patients who cannot tolerate a full surgical repair, endoscopic alternatives exist. The alpha-loop maneuver, a technique where the endoscope is deliberately looped inside the stomach to untwist it, has been used to reduce the volvulus without an incision. After the twist is undone, a percutaneous endoscopic gastrostomy (PEG) tube can be placed through the abdominal wall into the stomach. The tube serves double duty: it provides a feeding route if needed and it acts as a physical anchor that keeps the stomach from rotating again.20PubMed. Use of single percutaneous endoscopic gastrostomy in management of gastric volvulus in three patients This approach has been reported as successful in small series, though the evidence base is thin and it is generally reserved for patients who are poor candidates for laparoscopic or open repair.
Laparoscopic gastropexy alone, without hernia repair or fundoplication, has also been described as a standalone option for chronic gastric volvulus, particularly when the volvulus has been reduced endoscopically first.21PubMed Central. Chronic Gastric Volvulus with Laparoscopic Gastropexy after Endoscopic Reduction: A Case Report The approach is simpler and faster than a full hernia repair, which matters for patients with significant comorbidities.
Gastric Volvulus in Children
Management in pediatric patients follows a similar logic but the specifics differ. In a systematic review of 122 children with gastric volvulus, the initial approach was surgical in the majority, with gastropexy (anchoring the stomach) being the most commonly performed operation. Complications occurred in about 19% of the children, with narrowing of the esophagus being the most frequent. Eight children in the series died, a mortality rate of about 6%, and there was only one recorded recurrence after endoscopic management.22PubMed. Management and outcomes of gastric volvulus in children: a systematic review
A longer-term follow-up study looked at children who underwent a specific laparoscopic gastropexy technique combined with hiatal hernia correction. At 10 to 12 years of follow-up, all patients had the stomach in the correct position on imaging, none had recurrent volvulus, and most were symptom-free. Two patients reported occasional upper abdominal pain with vomiting, and follow-up endoscopy in those cases showed inflammation of the stomach and duodenum rather than recurrent twisting.23PubMed. Pediatric Gastric Volvulus: Is Laparoscopic Hill-Snow-Modified Gastropexy the Effective Long-Term Minimally Invasive Solution? Refeeding started the day after surgery and the average hospital stay was about six days, which gives families a reasonable sense of what to expect.
The Wandering Spleen Connection
One of the more unusual associations with gastric volvulus is a condition called wandering spleen. Normally, the spleen sits in the upper left part of the abdomen, held in place by the same set of peritoneal ligaments that stabilize the stomach. When those ligaments are lax or missing, the spleen can drift to an abnormal location, and the stomach can rotate with it or independently. Both conditions share the same root cause.24PubMed Central. An Adult Case of Gastric Volvulus Associated With Wandering Spleen: A Case Report In rare cases, the pancreas can twist along with both organs, producing a triple volvulus that causes acute abdominal pain demanding emergency surgery.5PubMed Central. Pancreatic volvulus with wandering spleen and gastric volvulus: an unusual triad for acute abdomen in a surgical emergency
Wandering spleen is itself quite rare, and the coexistence of both conditions in the same patient is rarer still. But the shared mechanism is worth knowing about because it changes how surgeons approach the operation. If a wandering spleen is found during surgery for gastric volvulus, it typically needs to be addressed at the same time, either by anchoring it in its normal position (splenopexy) or, in some cases, removing it. Failing to deal with the spleen during the index operation can lead to splenic torsion later, which is its own emergency.
Why This Condition Gets Missed
Gastric volvulus is often called a “diagnostic challenge,” and the reasons are mostly practical rather than exotic. The acute form mimics heart attacks, perforated ulcers, and bowel obstructions. The chronic form mimics reflux, irritable bowel, and functional dyspepsia. The condition is rare enough that many emergency physicians will go years without seeing a case, so it does not spring to mind the way a gallbladder attack or appendicitis would. The threshold for suspecting it should be lower in patients who are already known to have a large hiatal hernia, a history of bariatric surgery, or congenital diaphragmatic issues. In those groups, worsening upper abdominal symptoms, especially unproductive retching, warrant a CT scan sooner rather than later.
For patients with chronic, intermittent symptoms who have not gotten a clear diagnosis despite repeated visits, it is worth asking whether imaging has ever been done during an active episode. A stomach that looks normal on a scan taken on a good day can look dramatically twisted on a scan taken while symptoms are flaring. Timing imaging to coincide with symptoms, or ordering an upper GI barium study that captures the stomach in motion during swallowing, can sometimes catch what a routine scan misses.