73 year old lady with recurrent history of episodic right sided epigastric pain.
73 year old lady with recurrent history of episodic right sided epigastric pain presents in the Emergency department having been transferred from her care home. She gives a clear history of sudden onset of severe epigastric pain with retching.
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
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.
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
[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