Gastric Volvulus

Gastric volvulus is abnormal rotation of the stomach by more than approximately 180 degrees, producing obstruction with potential vascular compromise.

Two major forms are:

• Organoaxial: rotation around the line connecting the gastroesophageal junction and pylorus
• Mesenteroaxial: rotation around the short axis between greater and lesser curvatures

Organoaxial volvulus is more common in adults and frequently accompanies a large paraoesophageal hernia.

Acute volvulus can rapidly cause gastric venous obstruction, ischaemia, necrosis and perforation.

Acute presentation classically includes:

• Severe epigastric or lower chest pain
• Persistent retching with little vomitus
• Upper abdominal distension
• Difficulty passing a nasogastric tube

This combination forms the Borchardt triad but absence of one component does not exclude volvulus.

Haematemesis, severe persistent pain, peritonism, shock or rising lactate suggests gastric ischaemia or perforation.

Chronic intermittent volvulus may cause episodic postprandial pain, early satiety, dysphagia or intermittent vomiting.

CT chest and upper abdomen with IV contrast: confirms abnormal gastric rotation and assesses obstruction, paraoesophageal hernia and gastric viability.

Do not delay intervention for additional imaging when the stomach is clearly threatened.

Keep fasting, establish IV access and correct fluid and electrolyte deficits.

Attempt gentle nasogastric decompression when possible. Do not repeatedly force a tube through a distorted gastroesophageal junction.

A stable high risk patient with viable stomach may undergo urgent endoscopic decompression and detorsion as a temporising measure.

Fit patients with acute volvulus require definitive operative treatment because recurrence after decompression alone is common.

At operation:

• Reduce the volvulus
• Assess the entire stomach for viability
• Reduce associated paraoesophageal hernia
• Repair the diaphragmatic defect
• Fix the stomach to prevent recurrent rotation

Anterior gastropexy or another secure fixation technique is commonly used.

Resect clearly necrotic stomach. The extent ranges from limited wedge resection to partial or total gastrectomy according to the distribution of irreversible ischaemia.

Perforation or necrosis requires broad antimicrobial treatment, for example:

Piperacillin tazobactam 4.5 g IV every 8 hours by extended infusion, adjusted for renal function.

In frail patients unable to tolerate definitive hernia repair, endoscopic reduction followed by percutaneous gastrostomy fixation can provide less invasive recurrence prevention when the stomach is viable.