Discussion Author: Kevin Banks
Gastric volvulus occurs when the stomach twists on itself between the points of its normal anatomical fixation. It is clinically important as it may cause gastric outlet obstruction or vascular compromise resulting in a surgical emergency. Classically, it presents clinically with violent retching with little produced vomitus, severe epigastric pain and difficulty passing a nasogastric tube. Gastric volvulus is most common in the elderly but may occur at any age. It is usually associated with large sliding or para-esophageal hiatal hernias. Most of the time gastric volvulus involves a stomach which is partially or totally in the thoracic cavity and which rotates between the normally positioned gastric ligaments. Other predisposing factors include phrenic nerve palsy, eventration of the diaphragm, traumatic diaphragmatic hernia, gastric distension and abnormalities of the spleen.
Gastric volvulus is often divided into two types depending on the plane of torsion. In organo-axial volvulus the stomach rotates along its long axis, which is a line drawn between the cardia and the pylorus. Rotation may be to the right or left. The configuration of the torsed stomach depends on the original shape and position of the stomach (horizontal or vertical). If the normal stomach was in a horizontal position, volvulus flips the stomach upward so that the greater curvature is superior to the lesser curvature. If the stomach was originally vertically orientated volvulus causes a rightâ€“left twist.
Mesenteroaxial volvulus is less common but more likely to have significant clinical consequences. In this type of volvulus the stomach rotates on an axis perpendicular to the long axis of the stomach along a line joining the middle of the lesser curvature to the greater curvature. This corresponds to the axis of the mesenteric attachments of the greater and lesser omentum. The characteristic appearance is an â€˜upside down stomachâ€™ with the distal antrum and pylorus assuming a position cranial to the fundus and proximal stomach. This type of volvulus is often associated with traumatic diaphragmatic ruptures.
Radiographic signs of gastric volvulus include a double air-fluid level of the stomach in the mediastinum and upper abdomen on upright plain film. On barium studies the stomach may be inverted with the greater curvature above the lesser curvature, or the pylorus above the cardia and the torsed area identified as the source of the obstruction.
Treatment is generally surgical with laproscopic reduction of the volvulus and subsequent gastropexy.
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