Continuing Education Activity

Gastric volvulus is a rare, clinical event that occurs in both adults and pediatric patients. In 1886, Berti was the first to describe a gastric volvulus after performing an autopsy on a female patient. A gastric volvulus occurs when the stomach rotates on itself at least 180 degrees along its transverse or longitudinal axis. Gastric strangulation is a complication that can occur after the development of acute gastric volvulus. Timely diagnosis and treatment of acute gastric volvulus can potentially decrease morbidity and mortality. Patients can simply present with mild abdominal pain associated with nausea and vomiting, without emesis. Other patients can present with sepsis from necrosis of their volvulus and similar chief complaints. This activity reviews the evaluation gastric volvulus and the role of the interprofessional team in managing this condition.

Objectives:

• Describe the pathophysiology of gastric volvulus.
• Outline the presentation of gastric volvulus.
• Summarize the treatment options available for gastric volvulus.
• Review the evaluation of gastric volvulus and the role of the interprofessional team in managing this condition.

Introduction

Gastric volvulus is a rare, clinical event that occurs in both adults and pediatric patients. In 1886, Berti was the first to describe a gastric volvulus after performing an autopsy on a female patient. A gastric volvulus occurs when the stomach rotates on itself at least 180 degrees along its transverse or longitudinal axis. Gastric strangulation is a complication that can occur after the development of acute gastric volvulus. Timely diagnosis and treatment of acute gastric volvulus can potentially decrease morbidity and mortality. Patients can simply present with mild abdominal pain associated with nausea and vomiting, without emesis. Other patients can present with sepsis from necrosis of their volvulus and similar chief complaints.[1][2]

Etiology

In 10% to 30% of cases, gastric volvulus is considered primary and results from laxity and disruption of the stomach's ligamentous attachments (gastrohepatic, gastrocolic, gastrolienal, and gastrophrenic). For the majority of cases, gastric volvulus is caused by a gastric, splenic, or diaphragmatic anatomic disorder, the most common being a diaphragmatic hernia or an abnormality in gastric function. The organoaxial rotation of the stomach as described by Singleton is the most common gastric volvulus (two-thirds of cases) and occurs when the stomach rotates around the pylorus and the gastroesophageal (GE) junction. Mesenteroaxial rotation is less common (one-third of cases), and occurs when the stomach rotates longitudinal line parallel to the gastrohepatic omentum.[3]

Epidemiology

Gastric volvulus occurs in children usually less than 1 year of age and occurs in older adults, those who are older than 50 years. There does not seem to a predilection for gastric volvulus for either gender or race. The most common cause of a gastric volvulus in both children and adults is a paraesophageal hernia.[4]

Pathophysiology

Gastric volvulus causes a foregut obstruction in the patients. Gastric volvulus may present either acutely, or it may present with intermittent, recurrent, and chronic symptoms. When the stomach twist on itself there is always a risk for stomach strangulation with necrosis, perforation, and shock. The mortality for an acute volvulus can range from 30% to 50%, thus highlighting the importance of early diagnosis and treatment of gastric volvulus.

History and Physical

A patient's clinical presentation depends on the speed of onset, the type of stomach rotation (volvulus), and the completeness of the foregut obstruction. The presentation of an acute gastric volvulus can be quite severe with acute epigastric abdominal pain associated with severe retching. In 1904, Borchardt described the triad of acute epigastric pain, retching with the inability to vomit, and the difficulty or inability to pass a nasogastric tube. This triad occurs in up to 70% of patients who present with an acute organoaxial volvulus. The nasogastric tube passes easily in patients who present with an acute mesenteroaxial volvulus, as the lower esophageal sphincter remains open. The opposite is appreciated with organoaxial volvulus, as the nasogastric tube is more difficult to pass, due to the involvement of more proximal structures including the lower esophageal sphincter, the fundus, or the cardia. Patients who present with chronic, intermittent, and vague signs and symptoms of upper abdominal pain, nausea, dysphagia, early satiety vomiting, and hiccups may have a chronic partial or intermittent gastric volvulus.

Evaluation

The diagnosis of a gastric volvulus can be suspected with a good history and physical exam; however, diagnosis can be difficult. The diagnosis of a gastric volvulus may be confirmed radiologically when patients are symptomatic. Plain chest x-ray films that are suspicious for a gastric volvulus are those that demonstrate a spherical stomach or a double air-fluid level on upright chest films and the retrocardiac air-fluid level above the diaphragm on lateral chest film. Albas et al. described 4 radiologic findings predictive for a gastric volvulus on an upper gastrointestinal (GI) contrast study by showing gastric air-fluid level above the diaphragm, a paucity of distal bowel gas, reversal of the relative position of the greater curvature of the stomach, and a downward pointing pylorus. A barium swallow may be helpful as an adjunct to chest x-ray. Computed tomography (CT) scans of the chest, abdomen, and pelvis can also be diagnostic. CT scan of the chest, abdomen, and pelvis can provide information about the nature of volvulus, and other intraabdominal organs that may be involved, thus assisting pre-operative planning.

Treatment / Management

The traditional treatment for a patient presenting with an acute gastric volvulus has been an immediate operation reducing and untwisting the volvulus. This remains the gold standard; however, attempted medical management may be useful in patients that are a very high risk for surgery. Immediate surgical resection is required for necrosis or perforation of the stomach. Simultaneously, the diaphragmatic hernia should be reduced and closed. The stomach is then fixed to the anterior abdominal wall with suture, or by the placement of a gastrostomy tube. Open surgery, or the combination of laparoscopic and endoscopic surgical techniques, have good results. Laparoscopy, when used to repair chronic and intermittent gastric volvulus, is often be less morbid than an open operation. Patients who are fit enough to undergo a surgical procedure should proceed to have their chronic gastric volvulus repaired because of the high morbidity and mortality (30% to 50%) associated with strangulated gastric volvulus.[5][6]

Good results have also been reported with conservative treatment of an acute gastric volvulus in elderly patients if they are not presenting in extremis. Conservative treatment has also been used to help patients with intermittent and chronic volvulus.  The patient should be kept sitting upright, and a nasogastric tube should be gently inserted to decompress the stomach. The patient should be adequately resuscitated and re-evaluated often. Some high-risk, elderly patients can be treated endoscopically with decompression and reduction of the stomach, and placement of a percutaneous gastrostomy tube to gastropexy the stomach to the abdominal wall. Percutaneous gastrostomy placement can be done as an adjunct in ill patients with chronic or intermittent volvulus, or that may have other critical issues that need to be handled before definitive surgery, for example, sepsis from another source.

Differential Diagnosis

The differential diagnosis for gastric volvulus is very broad. The following are potential differential diagnosis:

• Gastroesophageal reflux disease
• Peptic ulcer disease
• Esophageal cancer
• Esophageal motility disorders
• Esophageal diverticulum
• Gastric cancer
• Gastroparesis

Enhancing Healthcare Team Outcomes

The diagnosis and management of gastric volvulus is complex and best done with an interprofessional team that includes a radiologist, emergency department physician, general surgeon, gastroenterologist, and an intensivist. Delay in diagnosis or treatment can be fatal. Some patients may be managed with conservative treatment that includes decompression of the stomach, but most patients benefit from surgery.

Strangulated gastric volvulus is associated with mortality rates in excess of 30% and these patients need monitoring by ICU nurses. Even after surgery, patients may develop complications that can prolong recovery. The outcomes for most patients are guarded.