Gastric volvulus
Updates to Article Attributes
Body
was changed:
Gastric volvulus is a specific type of volvulus that occurs when the stomach twists on its mesentery. It should be at least 180° and cause bowel obstruction to be called gastric volvulus. Merely gastric rotation on its root is not considered gastric volvulus.
Epidemiology
Organo-axial volvulus is more common in adults, responsible for 60% of presentations. Mesentero-axial volvulus is more common in children.
Clinical presentation
Patients may present with the classic triad of Borchardt:
- severe sudden epigastric pain
- intractable retching without vomiting
- inability to pass a nasogastric tube
Chronic symptoms are more common in patients with mesentero-axial volvulus.
Pathology
Subtypes
Organo-axial volvulus
- more common of the two types in adults (2/3 of cases)
- commonly occurs in the setting of trauma or para-oesophageal hernia
- stomach is rotated along its long axis (along the cardiopyloric line, which is drawn between the cardia and the pylorus)
- mirror image of normal anatomy can occur with reversal of the greater and lesser curves
- antrum rotates anterosuperiorly
- fundus rotates posteroinferiorly
- complete (>180º) present with obstruction or ischemia
- incomplete rotation (<180º) also called organo-axial position of the stomach, usually asymptomatic
Mesentero-axial volvulus
- less common in adults, but is more common than organo-axial volvulus in the paediatric population (59% of gastric volvulus)
- rotation around short axis from the lesser to greater curvature (i.e. perpendicular to the cardiopyloric line)
- usually incomplete, <180°
- displacement of antrum above gastro-oesophageal junction; stomach appears upside-down with the antrum and pylorus superior to the fundus and proximal body
- coincides with the axis of mesenteric attachment and is associated with severe obstruction and strangulation
- less associated with diaphragmatic defect
- plain films may show an intrathoracic stomach with two air fluid levels 1
Associations
- wandering spleen 2
- congenital diaphragmatic hernia
- diaphragmatic eventration
- laparoscopic adjustable gastric banding 4
Radiographic features
Plain radiograph
Unexpected location of the gastric bubble and air-fluid levels in the mediastinum or upper abdomen.
- chest radiograph
- intrathoracic; upside-down stomach
-
mediastinal or retrocardiac
fluidair-fluid level
-
mediastinal or retrocardiac
- intrathoracic; upside-down stomach
- abdominal radiograph; when performed with the patient upright
- unexpected location of the gastric bubble
- double air-fluid level
- large, distended stomach
- collapsed small bowel
Fluoroscopy
Upper GI
- distended stomach in left upper quadrant extending into thorax
- inversion of stomach
- volvulus with >180° twist causes luminal obstruction
- incomplete or absent entrance of contrast material into and/or out of stomach is indicative of acute obstructive volvulus
- "beaking" may be demonstrated at point of twist
- mesenteroaxial: antrum and pylorus lie above gastric fundus
CT
The appearance depends on points of torsion, extent of gastric herniation, and final positioning of stomach:
- distended stomach with antropyloric transition point, located at the level of or superior to the fundus 9
- linear septum may be visible within the gastric lumen which corresponds to the site of torsion
- entire stomach may be herniated (type IV paraoesophageal hernia (PEH)) or only part of it (type III PEH)
- both can result in
- volvulus
- obstruction
- ischaemia
- ischaemia seen as lack of contrast enhancement of gastric wall, with or without pneumatosis
- both can result in
Treatment and prognosis
Surgical repair, including stomach detorsion and gastropexy, is the main treatment modality for gastric volvulus. Detorsion may be performed open or laparoscopically. If the stomach is strangulated or necrotic, gastric resection may be required.
Differential diagnosis
- epiphrenic diverticulum
- postoperative state of the stomach
- hiatal hernia
-</ul><h4>Radiographic features</h4><h5>Plain radiograph</h5><p>Unexpected location of the gastric bubble and air-fluid levels in the mediastinum or upper abdomen.</p><ul>-<li>chest radiograph<ul><li>intrathoracic; upside-down stomach<ul><li>retrocardiac fluid level</li></ul>- +</ul><h4>Radiographic features</h4><h5>Plain radiograph</h5><ul>
- +<li>chest radiograph<ul><li>intrathoracic; upside-down stomach<ul><li>mediastinal or retrocardiac air-fluid level</li></ul>
- +<li>unexpected location of the gastric bubble </li>
References changed:
- 9. Millet I, Orliac C, Alili C, Guillon F, Taourel P. Computed Tomography Findings of Acute Gastric Volvulus. Eur Radiol. 2014;24(12):3115-22. <a href="https://doi.org/10.1007/s00330-014-3319-2">doi:10.1007/s00330-014-3319-2</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/25278244">Pubmed</a>
- 9. Millet I, Orliac C, Alili C, Guillon F, Taourel P. Computed tomography findings of acute gastric volvulus. (2014) European radiology. 24 (12): 3115-22. <a href="https://doi.org/10.1007/s00330-014-3319-2">doi:10.1007/s00330-014-3319-2</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/25278244">Pubmed</a> <span class="ref_v4"></span>
Images Changes:
Image ( update )
Position
was set to
.
Image 10 Barium ( update )
Position
was set to
.
Image 11 Fluoroscopy ( update )
Position
was set to
.
Image 12 CT (C+ arterial phase) ( update )
Position
was set to
.
Image 14 CT (C+ portal venous phase) ( update )
Position
was set to
.
Image 15 CT (C+ portal venous phase) ( update )
Position
was set to
.
Unable to process the form. Check for errors and try again.