What is Gastric Volvulus?
Gastric volvulus, a condition in which the stomach twists upon itself by at least 180 degrees, is an uncommon medical event in adults and children. It was first identified in 1886 by a physician named Berti during an autopsy procedure on a female patient. One serious complication that can stem from this condition is gastric strangulation. If gastric volvulus is diagnosed and treated quickly, it can dramatically reduce the risk of severe health effects and even death. Symptoms can range from mild stomach pain combined with nausea and vomiting (but without actually throwing up). In more severe cases, patients with this condition could develop sepsis, a dangerous body-wide infection caused by the death of tissue in their twisted stomach, with symptoms similar to the previous ones described.
What Causes Gastric Volvulus?
In 10% to 30% of cases, a condition known as gastric volvulus happens because the connections that hold the stomach in place (the gastrohepatic, gastrocolic, gastrolienal, and gastrophrenic ligaments) become loose or disturbed. However, most of the time, gastric volvulus happens because of problems with the stomach, spleen, or diaphragm. The most common issue is a diaphragmatic hernia, which is when parts of the stomach push up through the diaphragm, or problems with how the stomach works.
The stomach can twist around two main axes. The most common one (in two-thirds of cases) is called an organoaxial rotation, where the stomach rotates around the link between the stomach and the small intestine (the pylorus), and the link between the stomach and the esophagus (GE junction).
The less common kind of rotation (in one-third of cases) is called a mesenteroaxial rotation, where the stomach twists along lines that run parallel to the gastrohepatic omentum. This is a fatty structure in the upper abdomen that connects the stomach to the liver.
Risk Factors and Frequency for Gastric Volvulus
Gastric volvulus is a condition that mainly impacts two age groups – children under 1 year old and adults over 50. It doesn’t favor any particular gender or race. The most common cause of gastric volvulus in both kids and adults is a medical condition known as a paraesophageal hernia.
Signs and Symptoms of Gastric Volvulus
The symptoms a person suffers from in case of stomach rotation, or gastric volvulus, depends on how quickly it occurs, what type of stomach rotation they have, and how blocked their upper digestive tract is. Acute gastric volvulus can cause severe stomach pain and retching, a type of severe vomiting.
In 1904, Borchardt talked about a set of three symptoms known as a triad that occur in up to 70% of patients with an acute organoaxial volvulus (one form of stomach rotation): intense stomach pain, intense vomiting attempts but being unable to vomit, and trouble passing a nasogastric tube (a tube that goes through your nose into your stomach).
For patients with an acute mesenteroaxial volvulus (another type of stomach rotation), the nasogastric tube usually passes easily because the muscular ring at the bottom of the esophagus is open. But for those with organoaxial volvulus, it’s harder to pass the tube because structures nearer to the mouth, like the bottom of the esophagus and the top of the stomach, are involved.
People who have recurring, unclear symptoms like upper stomach pain, nausea, difficulty swallowing, feeling full early into a meal, vomiting, and hiccups might have a chronic (long-lasting), partial, or intermittent (comes and goes) stomach rotation.
Testing for Gastric Volvulus
If you’re showing symptoms of what could be a gastric volvulus, which is a twisting of the stomach, your doctor might be able to identify the condition through a careful review of your symptoms and a physical exam. However, diagnosing gastric volvulus can sometimes be difficult, so additional tests might be needed.
Your doctor might order a plain chest x-ray. Certain patterns on this x-ray, such as a round-looking stomach or two levels of air and fluid in your stomach, could suggest that you have a gastric volvulus. When looking from the side, your x-ray might also show a level of air and fluid behind your heart and above your diaphragm, the muscle that helps you breathe, which might also indicate a gastric volvulus.
An upper gastrointestinal (GI) contrast study could help confirm the diagnosis. This is a type of x-ray study where you swallow a special dye that helps to clearly outline your stomach on the x-ray. There are four main things the doctor might look for in this study: a level of air and fluid in your stomach that’s above your diaphragm, a lack of gas in the lower part of your bowel, a change in the usual position of the upper part of your stomach, and the lower part of your stomach (the pylorus) pointing downwards.
A barium swallow test might also be helpful. For this test, you swallow a liquid that contains a substance called barium, which outlines your esophagus, stomach and the upper part of your small intestine on an x-ray.
Your doctor might also order a computed tomography (CT) scan of your chest, abdomen, and pelvic area. This scan can provide detailed images of your stomach and other organs in your abdomen, which can help in diagnosing a gastric volvulus and planning for potential surgery, if necessary.
Treatment Options for Gastric Volvulus
When someone experiences an acute gastric volvulus, a condition where the stomach twists around itself, the standard treatment is immediate surgery. This treatment involves reducing and untwisting the stomach. In certain situations, particularly if the stomach tissue has died (necrosis), or a hole has formed in the stomach wall (perforation), the stomach must be removed entirely.
However, not everyone is a good candidate for surgery. If a person is deemed high risk, a different approach might be considered to manage their condition. This approach typically consists of reducing the hernia (a condition where an organ pushes through a hole in the muscles or tissues that hold it in place) and closing it up. This is done in combination with attaching the stomach to the front wall of the abdomen. It can be achieved either through a suture or by using a gastrostomy tube, which is a medical device that allows doctors to introduce or remove substances from the stomach.
Different techniques can be used to get the best result from this surgical procedure. It could be carried out through an open surgery or by using a combination of laparoscopic and endoscopic surgical techniques. A laparoscopy involves making small incisions and inserting a camera to perform the surgery, while an endoscopy makes use of a flexible tube with a light and camera attached to see parts of the digestive tract. This procedure is often less severe in terms of recovery than open surgery, especially when dealing with chronic or intermittent gastric volvulus.
Nonetheless, if the patient’s health permits, the preferred approach is surgical repair for chronic gastric volvulus. This is due to the high risk associated with a strangulated gastric volvulus, where the twisting of the stomach cuts off its blood supply. This could potentially lead to life-threatening conditions, with between 30% to 50% of people developing serious complications or dying as a result.
Conservative treatments may be considered for older patients who are not in critical condition as a result of acute gastric volvulus. These treatments are also applicable for people with intermittent and chronic volvulus. Keeping the patient upright, decompressing the stomach with the use of a nasogastric tube (a tube inserted through the nose down into the stomach), and consistent patient checks are part of this treatment. Also, using an endoscopic approach, high-risk elderly patients can have their stomach decompressed and reduced, along with the placement of a percutaneous gastrostomy tube to attach the stomach to the abdominal wall.
This tube can also be used in people with chronic or intermittent volvulus, or those who have other critical health issues that need to be managed before the main surgery can take place, such as a severe bodywide infection (sepsis).
What else can Gastric Volvulus be?
When a doctor is trying to diagnose gastric volvulus, or a twisting of the stomach, they have to consider many other possible conditions that could be causing the problem. These conditions could include:
- Gastroesophageal reflux disease (acid reflux)
- Peptic ulcer disease (stomach ulcers)
- Esophageal cancer (cancer in the tube connecting your throat to your stomach)
- Esophageal motility disorders (problems with the movement of food down the esophagus)
- Esophageal diverticulum (a pouch in the wall of the esophagus)
- Gastric cancer (stomach cancer)
- Gastroparesis (slow emptying of the stomach)
