Gastric Volvulus: A Comprehensive Guide To Diagnosis And Management

Gastric volvulus is a rare condition involving the twisting of the stomach, resulting in obstruction. Acute volvulus is characterized by the Borchardt triad (epigastric pain, retching without vomiting, and inability to pass a nasogastric tube) and is best diagnosed by CT scan. Chronic volvulus is less severe and can be diagnosed with barium swallow or endoscopy. Classification includes organoaxial (twisting along the stomach’s long axis) and mesenteroaxial (twisting along the transverse axis). Severity can be classified as closed-loop (hemodynamically significant) or open-loop (less severe). Timely diagnosis is crucial to avoid complications, with imaging techniques such as CT scan, barium swallow, and endoscopy playing critical roles in evaluation.

Understanding Gastric Volvulus: A Comprehensive Guide

Gastric volvulus is a rare but potentially life-threatening condition that occurs when the stomach twists on itself, disrupting blood flow and impeding the passage of food and fluids. Understanding the different types of gastric volvulus and their characteristic imaging findings is crucial for timely diagnosis and appropriate intervention.

Epidemiology and Definition

Gastric volvulus affects approximately 1 in 100,000 individuals worldwide. It is more common in elderly patients and those with certain underlying conditions, such as diaphragmatic hernias and neurologic disorders that weaken the stomach’s supporting structures.

Types of Gastric Volvulus

There are several ways to classify gastric volvulus based on the severity, rotation axis, and degree of obstruction.

Rotation Axis

• Organoaxial Volvulus: The stomach rotates around its long axis, resulting in a “twisted stomach” appearance.
• Mesenteroaxial Volvulus: The stomach rotates around its mesenteric attachment, leading to a “C”-shaped or “J”-shaped configuration.

Degree of Obstruction

• Closed-Loop Volvulus: The stomach twists completely, creating a closed loop that traps gas and fluids and can lead to strangulation and tissue death.
• Open-Loop Volvulus: The stomach twists partially, allowing some passage of contents and reducing the risk of complications.

Types of Gastric Volvulus: Acute and Chronic

Gastric volvulus, a condition where the stomach twists upon itself, can manifest in two primary forms: acute and chronic.

Acute Gastric Volvulus

Acute gastric volvulus is a medical emergency, often developing suddenly. Its pathophysiology involves a sudden twisting of the stomach along its mesentery, the tissue that connects it to the abdominal wall. This twisting can obstruct the flow of blood and contents into and out of the stomach.

The classic clinical presentation known as Borchardt triad includes:
* Severe epigastric pain
* Retching without vomiting
* Abdominal distension

Acute gastric volvulus can be life-threatening if not promptly diagnosed and treated. Imaging, particularly computed tomography (CT), plays a crucial role in aiding diagnosis by revealing typical findings such as a grossly distended stomach, whirl sign, or beak sign.

Chronic Gastric Volvulus

Chronic gastric volvulus, in contrast, develops gradually over time. It primarily affects elderly patients with diaphragmatic weakness or deformities. Unlike acute gastric volvulus, it often does not cause severe pain or obstruction. Instead, patients may experience intermittent bloating, early satiety, and difficulty swallowing.

Etiologies of chronic gastric volvulus include congenital abnormalities, acquired hernias, and adhesions. Because of its insidious onset and less severe symptoms, chronic gastric volvulus may be challenging to diagnose.

Classifying Gastric Volvulus by Rotation Axis

Understanding the different types of gastric volvulus is crucial for accurate diagnosis and timely intervention. One way to classify gastric volvulus is based on the rotation axis.

a) Organoaxial Volvulus

Organoaxial volvulus occurs when the stomach twists along its own longitudinal axis. This type of volvulus is usually congenital, meaning that it is present from birth. It is often associated with other structural abnormalities of the stomach and other organs.

On barium swallow, organoaxial volvulus appears as a “corkscrew” appearance of the stomach with a narrowed pylorus (the opening between the stomach and the small intestine). During endoscopy, the endoscope may encounter difficulty passing through the narrowed pylorus, and the stomach may appear rotated and twisted.

b) Mesenteroaxial Volvulus

Mesenteroaxial volvulus occurs when the stomach twists along its mesenteric axis. This type of volvulus is more common than organoaxial volvulus and can occur in both adults and children. It is often caused by a combination of factors, including a weakened gastrohepatic ligament (which normally helps to hold the stomach in place) and a sudden increase in abdominal pressure (such as from heavy lifting or a blow to the abdomen).

On barium swallow, mesenteroaxial volvulus appears as a “reverse corkscrew” appearance of the stomach with a widened pylorus. During endoscopy, the endoscope can usually pass through the pylorus without difficulty, and the stomach may appear rotated and twisted.

Types of Gastric Volvulus by Degree of Obstruction

Gastric volvulus is a condition where the stomach twists on itself, obstructing the passage of food and fluids. The severity of the obstruction depends on the degree of twisting, which can be classified into two main types: closed-loop and open-loop volvulus.

Closed-Loop Volvulus

In closed-loop volvulus, the stomach twists completely, creating a closed loop that traps gas and fluid within the stomach. This type of volvulus is a medical emergency, as it can lead to gastric ischemia and necrosis, a life-threatening condition where the stomach tissue dies due to lack of blood flow.

Symptoms of closed-loop volvulus include severe abdominal pain, nausea, and vomiting. The pain may be sudden and intense, and the patient may experience a sense of fullness or pressure in the upper abdomen. Imaging studies, such as a CT scan or barium swallow, can confirm the diagnosis and show the characteristic “whirlpool” sign of a closed-loop volvulus.

Immediate treatment is crucial in closed-loop volvulus to decompress the stomach and restore blood flow. This typically involves endoscopic or surgical intervention to untwist the stomach and relieve the obstruction.

Open-Loop Volvulus

In open-loop volvulus, the stomach twists partially, creating an open pathway that allows some passage of food and fluids. This type of volvulus is less severe than closed-loop volvulus and may not cause immediate life-threatening complications.

Symptoms of open-loop volvulus can include abdominal pain, heartburn, and regurgitation. The pain is typically less severe than in closed-loop volvulus, and the patient may not experience a sense of fullness or pressure. Imaging studies may show the characteristic “C-shaped” or “S-shaped” stomach of open-loop volvulus.

Treatment for open-loop volvulus may involve conservative measures, such as medications to reduce stomach acid and prokinetics to improve gastric motility. In some cases, surgical intervention may be necessary to correct the underlying anatomical abnormality that caused the volvulus.

Diagnostic Techniques in Gastric Volvulus Radiology

When it comes to diagnosing gastric volvulus, radiology plays a crucial role. Imaging tests can provide valuable insights into the type, severity, and complications of this condition.

Computed Tomography (CT) Scan

CT scans are particularly useful in evaluating acute gastric volvulus. They can reveal the classic “whirl sign,” which represents the twisted stomach, as well as any associated mesenteric ischemia. By assessing the degree of twist and involvement of mesenteric vessels, CT scans help determine the urgency of intervention.

Barium Swallow

Barium swallow exams are helpful in detecting chronic gastric volvulus, which may not present as acutely. The barium solution coats the stomach and allows for visualization of its anatomy and motility. In chronic volvulus, barium swallow can demonstrate the enlarged, air-filled stomach and the distorted shape of the gastric outlet.

Endoscopy

Endoscopy offers a direct view of the stomach and can confirm the diagnosis of gastric volvulus. It also allows for assessment of any associated complications, such as erosions, ulcers, or perforations. In some cases, endoscopic reduction of the volvulus may be attempted, especially in open-loop volvulus.