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Gastric Volvulus

 

  • Uncommon
    • May occur in children due to congenital diaphragmatic defects
    • In adults, rarely occurs before age 50
      • Most common cause of gastric volvulus in adults are diaphragmatic defects
  • Stomach twists on itself
  • Etiologies
    • Abnormality of the suspensory ligaments of the stomach
      • Gastrohepatic
      • Gastrosplenic
      • Gastrocolic
      • Gastrophrenic
    • Unusually long gastrocolic and gastrohepatic mesentery
  • Classified as one of two types--organoaxial or mesenteroaxial

 

Type

Appearance

Description

Remarks

Organoaxial

Twist occurs along a line connecting the cardia and the pylorus--the luminal (long) axis of the stomach

· Most common type.

· Usually associated with diaphragmatic defects.

· Vascular compromise more common.

Mesenteroaxial

Twist occurs around a plane perpendicular to the luminal (long) axis of the stomach from lesser to greater curvature

· Chronic symptoms more common.

· Diaphragmatic defects less common.

 

  • Almost always occur with large diaphragmatic hernia like hiatal hernia
    • Especially, paraesophageal hiatal hernias
      • In paraesophageal hernias, gastroesophageal junction remains in abdomen while stomach ascends adjacent to the esophagus
      • Produces “upside-down-stomach”
      • Gastric volvulus is most common complication of paraesophageal hernias
    • Also occurs with eventration of the diaphragm
    • Paralysis of diaphragm
  • Despite abnormal placement of stomach, it usually does not become obstructed
    • Sometimes called “partial volvulus” or “torsion” or “chronic volvulus”
    • Twisting up to 180 degrees may cause no obstruction
    • Twisting beyond 180 degrees almost always produces obstruction
  • Clinical findings
    • Unless acute, patients are frequently asymptomatic
    • When acute and obstructing
      • Abdominal pain
      • Attempts to vomit without results
      • Inability to pass an NG tube
      • Together, these three findings comprise the Borchardt triad which is diagnostic of acute volvulus
        • Reportedly occurs in 70% of cases
  • Imaging findings
    • Massively dilated stomach in LUQ possibly extending into chest
    • Inability of barium to pass into stomach (when obstructed)

Frontal radiograph from an upper GI examination shows the stomach
located in the lower chest in a large hiatal hernia. The greater curvature
of the stomach lies superior to the lesser curvature in an organoaxial twist.
Note that the stomach is not obstructed.

 

  • Treatment
    • Surgery in acute gastric volvulus
    • In patients with  chronic gastric volvulus, surgery is performed to prevent complications
      • Nonoperative mortality rate = as high as 80%
      • Mortality rate from acute gastric volvulus = 15-20%
      • Mortality rate from chronic gastric volvulus ranges up to 13%
  • Complications
    • Gastric emphysema
    • Twisting of stomach may tear spleen from its normal attachments
    • Perforation is rare

 

  • Margulis and Burhenne-Alimentary Tract Roentgenology  2nd Ed, Vol. 1
  • Dahnert 4th edition
  • eMedicine Gastric Volvulus by Mohamed Akoad, MD and Richard Golub, MD

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