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Gastric Volvulus

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Gastric Volvulus Author: William W Hope, MD; Chief Editor: John Geibel, MD, DSc, MA more... Updated: Mar 4, 2013

Background Gastric volvulus is a rare clinical entity defined as an abnormal rotation of the stomach of more than 180°, creating a closed-loop obstruction that can result in incarceration and strangulation. Berti first described gastric volvulus in a female autopsy patient in 1866.[1] Years later, in 1896, Berg performed the first successful operation for this condition.[2] In 1904, Borchardt described the classic triad associated with gastric volvulus: severe epigastric pain, retching without vomiting, and inability to pass a nasogastric tube.[3] Because many cases of chronic volvulus are not diagnosed, the incidence and prevalence of gastric volvulus is unknown. Males and females are equally affected. About 10-20% of cases occur in children,[4] usually before age 1 year, but cases have been reported in children up to age 15 years.[5] Gastric volvulus in children is often secondary to congenital diaphragmatic defects. The condition is uncommon in adults younger than 50 years.[4] See also Anatomy of the Stomach, Volvulus, Disorders of Rotation/Fixation and Midgut Volvulus, Gallbladder Volvulus, Intestinal Volvulus, Intestinal Malrotation, Sigmoid and Cecal Volvulus, and Omental Torsion.

Classification The most frequently used classification system of gastric volvulus, proposed by Singleton,[6] relates to the axis around which the stomach rotates, including organoaxial, mesentericoaxial, and combined.

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,[7] 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.[8]

Mesentericoaxial type The mesentericoaxial 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 etiology comprises approximately 29% of cases of gastric volvulus.[7] Patients with mesentericoaxial gastric volvulus usually present without diaphragmatic defects and usually have chronic symptoms.

Combined type http://emedicine.medscape.com/article/2054271-overview

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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.[9]

Etiology According to etiology, gastric volvulus can be classified as either type 1 (idiopathic) or type 2 (congenital or acquired).

Type 1 Idiopathic gastric volvulus comprises two thirds of cases and is presumably due to abnormal laxity of the gastrosplenic, gastroduodenal, gastrophrenic, and gastrohepatic ligaments. This allows approximation of the cardia and pylorus when the stomach is full, predisposing to volvulus. 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. Miller and colleagues reviewed the anatomic defects associated with type 2 gastric volvulus in the pediatric population,[10] as presented in Table 1, below. Table 1. Anatomic Defects Associated With Gastric Volvulus (Open Table in a new window) Congenital defects

Diaphragmatic defects: 43% Gastric ligaments: 32% Abnormal attachments, adhesions, or bands: 9% Asplenism: 5% Small and large bowel malformations: 4% Pyloric stenosis: 2% Colonic distention: 1% Rectal atresia: 1%

Complicating gastroesophageal surgery Neuromuscular disorders

— Poliomyelitis

Source: Miller DL, Pasquale MD, Seneca RP. Gastric volvulus in the pediatric population. Arch Surg. Sep 1991;126(9):1146-9.[10] Causes of type 2 gastric volvulus The most common causes of gastric volvulus in adults are diaphragmatic defects. In cases of paraesophageal hernias, the gastroesophageal junction remains in the abdomen, whereas the stomach ascends adjacent to the esophagus, resulting in an upside-down stomach. Gastric volvulus is the most common complication of paraesophageal hernias. It has also been reported to complicate gastroesophageal surgery, neuromuscular disorders, and intra-abdominal tumors. Rarely, gastric volvulus may be a complication of liver transplantation and may be related to ligation of the hepatogastric ligament during the hepatectomy.[11] Gastric volvulus after laparoscopic left adrenalectomy [12] or laparoscopic adjustable gastric band placement,[13] or related to eventration of the diaphragm[14] or to a large-cell neuroendocrine carcinoma in the stomach[15] have been reported. Table 2, below, summarizes the causes of secondary gastric volvulus in adults. Table 2. Causes of Secondary Gastric Volvulus in Adults (Open Table in a new window) Diaphragmatic Gastroesophageal Neuromuscular Increased IntraDefects Surgery Disorder abdominal Pressure Hiatal hernia

Nissen fundoplication

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Motor neuron disease

Abdominal tumors

Conditions Leading to Diaphragmatic Elevation Phrenic nerve palsy 2/6

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Posttraumatic

Left lung resection Total esophagectomy

Poliomyelitis

Intrapleural adhesions Highly selective vagotomy

Myotonic dystrophy

Coronary artery bypass graft

Prognosis The nonoperative mortality rate for gastric volvulus is reportedly as high as 80%.[16] 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.[8, 9, 17] 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%.[16, 18]

Contributor Information and Disclosures Author William W Hope, MD Assistant Professor of Surgery, University of North Carolina at Chapel Hill School of Medicine; Director of Surgical Education, Department of Surgery, New Hanover Regional Medical Center/South East Area Health Education Center William W Hope, MD is a member of the following medical societies: American College of Surgeons, North Carolina Medical Society, and Society of American Gastrointestinal and Endoscopic Surgeons Disclosure: Ethicon Grant/research funds Research Coauthor(s) Mohamed Akoad, MD Liver Transplant Surgeon, Division of Hepatobiliary and Liver Transplantation, Department of Surgery, Veterans Administration Pittsburgh Healthcare System Disclosure: Nothing to disclose. Richard W Golub, MD, FACS Consulting Surgeon, Sarasota Memorial Hospital and Doctors Hospital; Consulting Surgeon, Intercoastal Medical Group Richard W Golub, MD, FACS is a member of the following medical societies: American College of Gastroenterology, American College of Surgeons, American Society for Gastrointestinal Endoscopy, American Society of Colon and Rectal Surgeons, Association for Academic Surgery, Association for Surgical Education, Crohns and Colitis Foundation of America, Society for Surgery of the Alimentary Tract, and Society of American Gastrointestinal and Endoscopic Surgeons Disclosure: Nothing to disclose. Chief Editor John Geibel, MD, DSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital

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John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract Disclosure: AMGEN Royalty Consulting; Ardelyx Ownership interest Board membership Additional Contributors David L Morris, MD, PhD, FRACS Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia David L Morris, MD, PhD, FRACS is a member of the following medical societies: British Society of Gastroenterology Disclosure: RFA Medical None Director; MRC Biotec None Director Juan B Ochoa, MD Assistant Professor, Department of Surgery, University of Pittsburgh School of Medicine; Medical and Scientific Director, HCN, Nestle Healthcare Nutrition Disclosure: Nothing to disclose. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Salary Employment

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