Overview
Definition:
Gastric volvulus is a rare condition characterized by the abnormal twisting of the stomach along its mesenteric axis by more than 180 degrees, leading to mechanical obstruction
It can be acute, intermittent, or chronic and is classified as either organoaxial (twisting around the gastroesophageal and pyloroduodenal axes) or mesenteroaxial (twisting around the long axis of the mesentery).
Epidemiology:
It is more common in adults, with a peak incidence in the sixth decade of life
Predisposing factors include paraesophageal hernias, laxity of the gastrosplenic and gastrocolic ligaments, and diaphragmatic defects
Primary gastric volvulus without a clear anatomical defect is less common.
Clinical Significance:
Gastric volvulus is a surgical emergency due to the risk of strangulation, ischemia, and perforation, leading to significant morbidity and mortality
Early recognition and prompt surgical intervention are crucial for favorable outcomes
Understanding its presentation and management is vital for surgical residents preparing for DNB and NEET SS examinations.
Clinical Presentation
Symptoms:
Epigastric pain, often severe and sudden onset in acute presentations
Persistent nausea and forceful, unproductive retching or vomiting
Abdominal distension, especially in the epigastrium
Difficulty in passing nasogastric tubes
Dyspnea or chest pain if the stomach ascends into the thorax
Symptoms can be intermittent in chronic cases, often relieved by postural changes.
Signs:
Abdominal tenderness, particularly in the epigastrium
Palpable, distended stomach
Signs of shock may be present in cases of strangulation or perforation
Chest X-ray may reveal a bizarre air-fluid level or a mass in the chest if a paraesophageal hernia is present
Vital sign abnormalities may include tachycardia and hypotension.
Diagnostic Criteria:
No specific formal diagnostic criteria exist
diagnosis relies on clinical suspicion, supported by characteristic imaging findings
The degree of gastric twisting is typically greater than 180 degrees, causing luminal obstruction and vascular compromise, which are the core pathophysiological elements.
Diagnostic Approach
History Taking:
Detailed history focusing on the onset, duration, and character of abdominal pain, nausea, and vomiting
History of previous abdominal surgery, trauma, or gastrointestinal symptoms
Presence of risk factors such as hiatal hernia, weight loss, or gastric surgery
Red flags include sudden onset of severe pain, signs of peritonitis, and hemodynamic instability.
Physical Examination:
Thorough abdominal examination to assess for distension, tenderness, guarding, and rebound tenderness
Auscultation for bowel sounds, which may be diminished or absent
Examination of the chest for respiratory compromise and assessment for a visible or palpable epigastric mass.
Investigations:
Plain abdominal X-ray: May show a distended stomach with an air-fluid level, often located in an unusual position (e.g., intrathoracic)
Upper GI series with barium: The gold standard, demonstrating the point of obstruction and the degree of torsion
CT scan of the abdomen and pelvis: Provides detailed anatomical information, identifies the degree of volvulus, and assesses for complications like ischemia or perforation
Endoscopy: May be difficult to pass through the obstruction, but can confirm intraluminal findings and assess mucosal viability.
Differential Diagnosis:
Peptic ulcer disease with gastric outlet obstruction
Gastric outlet obstruction due to malignancy
Intestinal obstruction
Acute pancreatitis
Cholecystitis
Mesenteric ischemia
Foreign body in the stomach
Hiatal hernia with gastric incarceration.
Management
Initial Management:
Immediate resuscitation with intravenous fluids and correction of electrolyte imbalances
Nasogastric tube decompression to relieve distension and prevent further vomiting
Broad-spectrum antibiotics should be initiated if perforation or strangulation is suspected
Analgesia should be provided for pain control.
Medical Management:
Primarily supportive care and stabilization
Medical management is not definitive
surgery is indicated for most cases, especially acute and symptomatic presentations.
Surgical Management:
Indications for surgery include acute gastric volvulus with signs of strangulation or perforation, recurrent or symptomatic intermittent gastric volvulus, and any gastric volvulus associated with a significant paraesophageal hernia
Laparoscopic reduction and gastropexy is the preferred approach
The procedure involves reducing the volvulus by untwisting the stomach, followed by fixation of the stomach to the anterior abdominal wall (gastropexy) to prevent recurrence
In cases of gastric necrosis, a gastrectomy may be required.
Supportive Care:
Close monitoring of vital signs, fluid balance, and urine output
Nutritional support may be required via parenteral nutrition if oral intake is not possible for an extended period
Postoperative pain management and early mobilization are essential.
Complications
Early Complications:
Gastric ischemia and perforation
Strangulation leading to gastric necrosis
Hemorrhage
Wound infection
Pneumonia
Anesthesia-related complications.
Late Complications:
Recurrence of gastric volvulus if gastropexy is inadequate or fails
Stricture formation at the gastropexy site
Chronic abdominal pain
Nutritional deficiencies.
Prevention Strategies:
Adequate fixation of the stomach to the abdominal wall during gastropexy
Ensuring complete reduction of the volvulus
Addressing any associated anatomical defects like paraesophageal hernias
Careful surgical technique to avoid injury to surrounding structures.
Prognosis
Factors Affecting Prognosis:
Promptness of diagnosis and surgical intervention
Presence and extent of gastric ischemia or perforation
Comorbidities of the patient
Technical success of the surgical procedure, particularly the adequacy of gastropexy.
Outcomes:
With timely laparoscopic reduction and gastropexy, the prognosis is generally good, with low morbidity and mortality rates
Patients typically experience relief from symptoms and a significant reduction in the risk of recurrence
Prognosis is poorer in cases with delayed presentation leading to perforation or extensive gastric necrosis.
Follow Up:
Regular follow-up appointments are necessary to monitor for recurrence and assess long-term outcomes
This typically involves clinical assessment and may include imaging if symptoms recur
Patients should be advised to report any new or worsening abdominal symptoms promptly.
Key Points
Exam Focus:
Differentiate organoaxial vs
mesenteroaxial volvulus
Recognize Borchardt's triad: sudden severe abdominal pain, retching with absence of vomiting, and inability to pass an NG tube
Understand the role of CT scan and barium swallow in diagnosis
Know the indications for laparoscopic vs
open surgery and the principles of reduction and gastropexy.
Clinical Pearls:
A high index of suspicion is crucial, especially in patients with unexplained upper abdominal pain and persistent vomiting
Always attempt NG tube placement when gastric outlet obstruction is suspected
inability to pass it is a significant clue
Laparoscopic gastropexy is vital to prevent recurrence after reduction.
Common Mistakes:
Delaying surgical intervention, leading to ischemia and perforation
Mistaking gastric volvulus for a simple gastric outlet obstruction or dyspepsia
Inadequate gastropexy leading to recurrence
Over-reliance on endoscopy without considering the risk of exacerbating ischemia in acute cases.