Radiology
Learning Case
73 year old lady with recurrent history of episodic right sided epigastric pain.
Discussion
Gastric volvulus is an abnormal rotation of the stomach of more than 180°, which creates a closed-loop obstruction that can result in incarceration and strangulation. It can manifest either as an acute abdominal emergency or as a chronic intermittent problem. The presenting symptoms depend on the degree of twisting and the rapidity of onset. Gastric volvulus is a rare condition. It is a difficult condition to diagnose, mostly because it is rarely considered.
The Borchardt triad (i.e., pain, retching, and inability to pass a nasogastric tube) is diagnostic of acute volvulus and reportedly occurs in 70% of cases [i]. The most frequently used classification system of gastric volvulus, proposed by Singleton [ii] relates to the axis around which the stomach rotates and includes the following three types
- Organoaxial
- Mesenteroaxial
- Combined
In etiologic terms, gastric volvulus can be classified as either type 1 (idiopathic) or type 2 (congenital or acquired). In a primary gastric volvulus, there is the absence of abnormal intra-abdominal pathology and diaphragmatic defects[iii]. This kind of volvulus occurs as a result of a neoplasm, adhesions or abnormalities of the ligamentous attachments of the stomach.
A secondary gastric volvulus occurs as a result of abnormalities of gastric anatomy, motility or abnormalities of the diaphragm or spleen [iv]. Most cases of gastric volvulus have a secondary cause such as a para-oesophageal hernia, peptic ulcers, bariatric surgery, abdominal adhesions and traumatic diaphragmatic injury.[v] This kind of volvulus occurs as a result of a neoplasm, adhesions or abnormalities of the ligamentous attachments of the stomach.
A PubMed literature review was performed involving all cases of a gastric volvulus reported from 1999 to 2018 (total of 43 case-reports). Of those cases, 67% were due to a secondary cause, 91% of them were treated with surgery and death was recorded in three patients vi.
Differential Diagnosis
Learning Points
Gastric volvulus is a rate entity with a high mortality rate when presenting acutely. Treatment is surgical vi. Therefore, it should be considered in the differential diagnosis in patients presenting with acute abdominal symptoms. Mortality 30% – 50% if delayed diagnosis
Videos
References
[i] Miller DL, Pasquale MD, Seneca RP, Hodin E. Gastric volvulus in the pediatric population. Arch Surg. 1991 Sep. 126 (9):1146-9.
[ii] Singleton AC. Chronic gastric volvulus. Radiology. 1940;34:53-61
[iii] Chau, B, Dufel, S. “Gastric Volvulus.” Emergency Medicine Journal. 2007 Jun; 24(6): 446-447
[iv] Rashid, F, Thangarajah, T, Mulvey, D, Larvin, M, Iftikher, S. “A review article on gastric volvulus: A challenge to diagnosis and management.” International Journal of Surgery. Volume 8, Issue 1, 2010, Pages 18-24
[v] Akhtar, A, Siddiqui, F, Sheikh, A.A, Sheikh, A.B, Perisetti, A. “Gastric Volvulus: A Rare Entity Case Report and Literature Review.” Cureus Journal of Medical Sciences. 2018 Mar; 10(3): e2312
[vi] https://www.dovepress.com/managing-obstructive-gastric-volvulus-challenges-and-solutions-peer-reviewed-fulltext-article-OAS