Gastric volvulus

Last updated
Gastric volvulus
Other namesVolvulus of stomach
Specialty General surgery

Gastric volvulus or volvulus of stomach is a twisting of all or part of the stomach by more than 180 degrees with obstruction of the flow of material through the stomach, variable loss of blood supply and possible tissue death. The twisting can occur around the long axis of the stomach: this is called organoaxial or around the axis perpendicular to this, called mesenteroaxial. Obstruction is more likely in organoaxial twisting than with mesenteroaxial while the latter is more associated with ischemia. About one third of the cases are associated with a hiatus hernia. Treatment is surgical.

Contents

The classic triad (Borchardt's Triad) of gastric volvulus, described by Borchardt in 1904, consists of severe epigastric pain, retching (due to sour taste in mouth) without vomiting, inability to pass a nasogastric tube and reportedly occurs in 70% of cases. Sometimes severe pain at the top of left shoulder, this may be due to internal bleeding irritating the diaphragm upon respiration.

Classification

Organoaxial type

In an organoaxial gastric volvulus, the stomach rotates around an axis that connects the gastroesophageal junction and the pylorus. The antrum rotates in opposite direction to the fundus of the stomach. This is the most common type of gastric volvulus, occurring in approximately 59% of cases, and it is usually associated with diaphragmatic defects. Strangulation and necrosis commonly occur with organoaxial gastric volvulus and have been reported in 5–28% of cases. The key imaging feature of organoaxial volvulus is that the greater curvature is located above the lesser curvature of the stomach. [1]

Mesenteroaxial type

The mesenteroaxial axis bisects the lesser and greater curvatures. The antrum rotates anteriorly and superiorly so that the posterior surface of the stomach lies anteriorly. The rotation is usually incomplete and occurs intermittently. Vascular compromise is uncommon. This cause comprises approximately 29% of cases of gastric volvulus. The key imaging feature of mesenteroaxial volvulus is that the antrum is above the gastroesophageal junction. [1]

Combined type

The combined type of gastric volvulus is a rare form in which the stomach twists mesentericoaxially and organoaxially. This type of gastric volvulus makes up the remainder of cases and is usually observed in patients with chronic volvulus.

Cause

Type 1

Gastric volvulus of unknown cause comprises two thirds of cases and is presumably due to abnormal laxity of the gastrosplenic, gastroduodenal, gastrophrenic, and gastrohepatic ligaments. Type 1 gastric volvulus is more common in adults but has been reported in children.

Type 2

Type 2 gastric volvulus is found in one third of patients and is usually associated with congenital or acquired abnormalities that result in abnormal mobility of the stomach.

Diagnosis

On chest radiography, a retrocardiac, gas-filled viscus may be seen in cases of intrathoracic stomach, which confirms the diagnosis. Plain abdominal radiography reveals a massively distended viscus in the upper abdomen. In organoaxial volvulus, plain films may show a horizontally oriented stomach with a single air-fluid level and a paucity of distal gas. In mesenteroaxial volvulus, plain abdominal radiographic findings include a spherical stomach on supine images and 2 air-fluid levels on erect images, with the antrum positioned superior to the fundus.

Upper GI studies

The diagnosis of gastric volvulus is usually based on barium studies; however, some authors recommend computed tomography (CT) scanning as the imaging modality of choice.

Upper gastrointestinal (GI) contrast radiographic studies (using barium or Gastrografin) are sensitive and specific if performed with the stomach in the "twisted" state and may show an upside-down stomach. Contrast studies have been reported to have a diagnostic yield in 81–84% of patients.

Often performed for an evaluation of acute abdominal pain, a computed tomography (CT) scan can offer immediate diagnosis by showing two bubbles with a transition line. Proponents of CT scanning in the diagnosis of gastric volvulus report several benefits, including:

  1. the ability to rapidly diagnose the condition based on a few coronal reconstructed images,
  2. the ability to detect the presence or absence of gastric pneumatosis and free air,
  3. the detection of predisposing factors (i.e., diaphragmatic or hiatal hernias), and
  4. the exclusion of other abdominal pathology.

Endoscopy

Upper gastrointestinal (GI) endoscopy may be helpful in the diagnosis of gastric volvulus. When this procedure reveals distortion of the gastric anatomy with difficulty intubating the stomach or pylorus, it can be highly suggestive of gastric volvulus. In the late stage of gastric volvulus, strangulation of the blood supply can result in progressive ischemic ulceration or mucosal fissuring.

The nonoperative mortality rate for gastric volvulus is reportedly as high as 80%. Historically, mortality rates of 30–50% have been reported for acute gastric volvulus, with the major cause of death being strangulation, which can lead to necrosis and perforation. With advances in diagnosis and management, the mortality rate from acute gastric volvulus is 15–20% and that for chronic gastric volvulus is 0–13%.

Related Research Articles

Stomach digestive organ

The stomach is a muscular, hollow organ in the gastrointestinal tract of humans and many other animals, including several invertebrates. The stomach has a dilated structure and functions as a vital digestive organ. In the digestive system the stomach is involved in the second phase of digestion, following chewing. It performs a chemical breakdown due to enzymes and hydrochloric acid.

Peptic ulcer disease Ulcer of an area of the gastrointestinal tract

Peptic ulcer disease (PUD) is a break in the inner lining of the stomach, the first part of the small intestine, or sometimes the lower esophagus. An ulcer in the stomach is called a gastric ulcer, while one in the first part of the intestines is a duodenal ulcer. The most common symptoms of a duodenal ulcer are waking at night with upper abdominal pain and upper abdominal pain that improves with eating. With a gastric ulcer, the pain may worsen with eating. The pain is often described as a burning or dull ache. Other symptoms include belching, vomiting, weight loss, or poor appetite. About a third of older people have no symptoms. Complications may include bleeding, perforation, and blockage of the stomach. Bleeding occurs in as many as 15% of cases.

Hernia abnormal exit of tissue or an organ through the wall of the cavity in which it normally resides

A hernia is the abnormal exit of tissue or an organ, such as the bowel, through the wall of the cavity in which it normally resides. Hernias come in a number of types. Most commonly they involve the abdomen, specifically the groin. Groin hernias are most common of the inguinal type but may also be femoral. Other hernias include hiatus, incisional, and umbilical hernias. Symptoms are present in about 66% of people with groin hernias. This may include pain or discomfort especially with coughing, exercise, or going to the bathroom. Often it gets worse throughout the day and improves when lying down. A bulging area may occur that becomes larger when bearing down. Groin hernias occur more often on the right than left side. The main concern is strangulation, where the blood supply to part of the bowel is blocked. This usually produces severe pain and tenderness of the area. Hiatus or hiatal hernias often result in heartburn but may also cause chest pain or pain with eating.

Peritonitis inflammation of the peritoneum, the lining of the inner wall of the abdomen

Peritonitis is inflammation of the peritoneum, the lining of the inner wall of the abdomen and cover of the abdominal organs. Symptoms may include severe pain, swelling of the abdomen, fever, or weight loss. One part or the entire abdomen may be tender. Complications may include shock and acute respiratory distress syndrome.

Hiatal hernia type of hernia in which abdominal organs (typically the stomach) slip through the diaphragm into the middle compartment of the chest

A hiatal hernia is a type of hernia in which abdominal organs slip through the diaphragm into the middle compartment of the chest. This may result in gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR) with symptoms such as a taste of acid in the back of the mouth or heartburn. Other symptoms may include trouble swallowing and chest pains. Complications may include iron deficiency anemia, volvulus, or bowel obstruction.

Gastric dilatation volvulus A medical condition in dogs

Gastric dilatation volvulus (GDV), also known as gastric dilation, twisted stomach, or gastric torsion, is a medical condition that affects dogs in which the stomach becomes overstretched and rotated by excessive gas content. The word bloat is often used as a general term to mean gas distension without stomach torsion, or to refer to GDV.

Pylorus anatomical organ that connects the stomach to the duodenum

The pylorus, or pyloric part, connects the stomach to the duodenum. The pylorus is considered as having two parts, the pyloric antrum and the pyloric canal. The pyloric canal ends as the pyloric orifice, which marks the junction between the stomach and the duodenum. The orifice is surrounded by a sphincter, a band of muscle, called the pyloric sphincter. The word pylorus comes from Greek πυλωρός, via Latin. The word pylorus in Greek means "gatekeeper", related to "gate" and is thus linguistically related to the word "pylon".

Nissen fundoplication

A Nissen fundoplication, or laparoscopic Nissen fundoplication when performed via laparoscopic surgery, is a surgical procedure to treat gastroesophageal reflux disease (GERD) and hiatal hernia. In GERD, it is usually performed when medical therapy has failed; but, with a Type II (paraesophageal) hiatus hernia, it is the first-line procedure. The Nissen fundoplication is total (360°), but partial fundoplications known as Thal, Belsey, Dor, Lind, and Toupet fundoplications are alternative procedures with somewhat different indications and outcomes.

Esophagogastroduodenoscopy a diagnostic endoscopic procedure that visualizes the upper part of the gastrointestinal tract down to the duodenum

Esophagogastroduodenoscopy, also called by various other names, is a diagnostic endoscopic procedure that visualizes the upper part of the gastrointestinal tract down to the duodenum. It is considered a minimally invasive procedure since it does not require an incision into one of the major body cavities and does not require any significant recovery after the procedure. However, a sore throat is common.

Gastric varices

Gastric varices are dilated submucosal veins in the stomach, which can be a life-threatening cause of bleeding in the upper gastrointestinal tract. They are most commonly found in patients with portal hypertension, or elevated pressure in the portal vein system, which may be a complication of cirrhosis. Gastric varices may also be found in patients with thrombosis of the splenic vein, into which the short gastric veins which drain the fundus of the stomach flow. The latter may be a complication of acute pancreatitis, pancreatic cancer, or other abdominal tumours, as well as hepatitis C. Gastric varices and associated bleeding are a potential complication of schistosomiasis resulting from portal hypertension.

Percutaneous endoscopic gastrostomy type of gastrostomy in which a tube is passed into the stomach through the abdominal wall

Percutaneous endoscopic gastrostomy (PEG) is an endoscopic medical procedure in which a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate. This provides enteral nutrition despite bypassing the mouth; enteral nutrition is generally preferable to parenteral nutrition. The PEG procedure is an alternative to open surgical gastrostomy insertion, and does not require a general anesthetic; mild sedation is typically used. PEG tubes may also be extended into the small intestine by passing a jejunal extension tube through the PEG tube and into the jejunum via the pylorus.

Colic in horses is defined as abdominal pain, but it is a clinical symptom rather than a diagnosis. The term colic can encompass all forms of gastrointestinal conditions which cause pain as well as other causes of abdominal pain not involving the gastrointestinal tract. The most common forms of colic are gastrointestinal in nature and are most often related to colonic disturbance. There are a variety of different causes of colic, some of which can prove fatal without surgical intervention. Colic surgery is usually an expensive procedure as it is major abdominal surgery, often with intensive aftercare. Among domesticated horses, colic is the leading cause of premature death. The incidence of colic in the general horse population has been estimated between 4 and 10 percent over the course of the average lifespan. Clinical signs of colic generally require treatment by a veterinarian.

Volvulus Human disease

A volvulus is when a loop of intestine twists around itself and the mesentery that supports it, resulting in a bowel obstruction. Symptoms include abdominal pain, abdominal bloating, vomiting, constipation, and bloody stool. Onset of symptoms may be rapid or more gradual. The mesentery may become so tightly twisted that blood flow to part of the intestine is cut off, resulting in ischemic bowel. In this situation there may be fever or significant pain when the abdomen is touched.

Intestinal malrotation is a congenital anomaly of rotation of the midgut. It occurs during the first trimester as the fetal gut undergoes a complex series of growth and development. Malrotation can lead to a dangerous complication called volvulus.

Congenital diaphragmatic hernia diaphragm disease characterized by the lack of development of all or part of the diaphragm, which results in an abnormal opening that allows the stomach and intestines to move into the chest cavity and crowd the heart and lungs

Congenital diaphragmatic hernia (CDH) is a birth defect of the diaphragm. The most common type of CDH is a Bochdalek hernia; other types include Morgagni hernia, diaphragm eventration and central tendon defects of the diaphragm. Malformation of the diaphragm allows the abdominal organs to push into the chest cavity, hindering proper lung formation.

Abdominal bloating is a symptom that can appear at any age, generally associated with functional gastrointestinal disorders or organic diseases, but can also appear alone. The person feels a full and tight abdomen. Although this term is usually used interchangeably with abdominal distension, these symptoms probably have different pathophysiological processes, which are not fully understood.

Ménétriers disease Human disease

Ménétrier disease is a rare, acquired, premalignant disease of the stomach characterized by massive gastric folds, excessive mucous production with resultant protein loss, and little or no acid production. The disorder is associated with excessive secretion of transforming growth factor alpha (TGF-α). It is named after a French physician Pierre Eugène Ménétrier, 1859–1935.

Gastric outlet obstruction Human disease

Gastric outlet obstruction (GOO) is a medical condition where there is an obstruction at the level of the pylorus, which is the outlet of the stomach. Individuals with gastric outlet obstruction will often have recurrent vomiting of food that has accumulated in the stomach, but which cannot pass into the small intestine due to the obstruction. The stomach often dilates to accommodate food intake and secretions. Causes of gastric outlet obstruction include both benign causes, as well as malignant causes, such as gastric cancer.

The Sugiura procedure is a surgical technique that involves the removal and transection of the blood vessels that supply the upper portion of the stomach and the esophagus. The procedure also involves a splenectomy. The operation was originally developed to treat bleeding esophageal varices that were untreatable by other conventional methods. It was originally developed as a two-step operation, but has been modified numerous times by many surgeons since its original creation.

Chronic gastritis Inflammation of the stomach that is chronic in nature

Chronic gastritis is a chronic inflammation of the gastric mucosa, as opposed to Acute Gastritis where the symptoms occur for a relatively short time.

References

  1. 1 2 Carter, R; Brewer LA, 3rd; Hinshaw, DB (July 1980). "Acute gastric volvulus. A study of 25 cases". American Journal of Surgery. 140 (1): 99–106. doi:10.1016/0002-9610(80)90424-9. PMID   7396092.
Classification
D
External resources