Revista Chilena de Radiologa. Vol. 18 N 3, ao 2012; 129-135.

GASTROINTESTINAL

Stomach volvulus: Why should we remember it?

Case review

Drs. Samuel Snchez C (1), Laura Vique B (2), Oscar Ardiles C (3), David Herquiigo R (4).

1. Radiologist, post-scholarship University of Chile Clinical Hospital, Santiago, Chile

2. Radiology Fellow, University of Chile Clinical Hospital, Santiago, Chile.
3. Physician in training at Imaging Center, University of Chile Clinical Hospital, Santiago, Chile
4. Radiologist, Assistant Professor Of Radiology, University of Chile Clinical Hospital, Santiago, Chile

Abstract: Stomach volvulus is a medical entity which has different implications in terms of clinical pre-
sentation, diagnosis, imaging support, and pathological behavior and evaluation. Analysis of features of
these implications is essential when deciding a course of action, which can vary from simple observa-
tion to aggressive and urgent resolutions in order to save the patients life. Gastric volvulus represents
an unusual rotation of the organ on its own axis, thus entailing risk of ischemia and necrosis. There are
two major types of gastric volvulus, i.e., organoaxial and mesenteroaxial. It can occur in any stage of
life, preferably in adulthood, with clinical signs of acute abdomen in most of the cases. Due to the risk
of ischemia, necrosis, and vital compromise, an urgent response involves surgical resolution which can
lead to the removal of the organ, with a high risk of mortality in the intra- and post-operative periods. We
report the case of a patient presenting with the aforementioned clinical processes.
Keywords: Borchardts triad, Gastrectomy, Stomach, Volvulus.

Resumen: El vlvulo gstrico es una entidad mdica de diversas implicancias en cuanto a la presentacin
clnica, diagnstico, apoyo imaginolgico, conducta y evaluacin patolgica. Por tanto, es fundamen-
tal la revisin de las caractersticas de cada una de ellas, con el objeto de orientar una conducta que
posee caracteres tan amplios como lo es la simple observacin hasta una conducta agresiva y urgente
que implique salvar la vida del paciente.El vlvulo gstrico consiste en una rotacin del rgano sobre
su propio eje, de baja ocurrencia, presentndose dos tipos: organoaxial y mesenteroaxial, en los cuales
existe riesgo de isquemia y necrosis. Se manifiesta en cualquier etapa de la vida, de preferencia en
etapa adulta y con clnica de abdomen agudo en gran parte de los casos. Debido al riesgo de isquemia,
necrosis y compromiso vital, la conducta urgente implica resolucin quirrgica, que puede concluir en
extirpacin del rgano, con un alto riego de mortalidad en el intra y postoperatorio.Presentamos el caso
de una paciente caracterstica en cuanto a la presentacin de los procesos clnicos antes mencionados.
Palabras clave: Estmago, Gastrectoma, Triada de Borchardt, Vlvulo.

Snchez S, et al. Vlvulo gstrico: Por qu recordarlo? Revisin a propsito de un caso. Rev Chil Radiol 2012;
18(3): 129-135.
Correspondence to: Dr. Samuel Snchez C. / [email protected]
Received july 07, 2012, accepted after revision october 02, 2012.

Introduction
Gastric volvulus is a clinical entity caused by An estimated 75-80% of cases correspond to
rotation of the stomach on its axis. This event of adult patients, whith clinical presentation usually as-
rare occurrence, less frequent than in other parts of sociated with predisposing congenital and acquired
the gastrointestinal tract, such as sigmoid, cecal or factors together.
midgut volvulus, may be transient, with non-specific Gastric volvulus should be carefully considered
symptoms, or may lead to an obstruction with ische- as the cause of epigastric pain and vomiting, since
mia and necrosis. misdiagnosis can lead to patients death.

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Radiology procedures provide the most significant

tool for diagnosis and subsequent therapeutic approach
to this pathology, primarily through basic and x-ray
contrast imaging, followed by CT scanning, which
represents an excellent tool for anatomic orientation
for treatment.
This work reports a case of gastric volvulus in
adult patient without known associated comorbidity
correlation with subsequent imaging, surgical, and
anatomopathological findings.

Case report
Female patient aged 81 years old, with Tako-Ttsubo
cardiomyopathy (transient apical dyskinesia) with
surgical history of cholecystectomy and right total hip
arthroplasty; she was brought to the emergency room
complaining of epigastric abdominal pain, nausea,
Figure 2. Coronal reconstruction of CT scan showing same
vomiting and fever within last 24 hours of evolution. findings described above, along with displacement and
Clinical examination detected a markedly distended compression of small-bowel loops into the pelvis.
abdomen, higly sensitive, and febricula.
Abdominal and pelvic CT scan is requested due to
suspected stuck umbilical hernia; it revealed a severe
gastric dilatation with organ folding extending up to
the pelvic excavation, compatible with organo-axial
gastric volvulus associated to gastric pneumatosis
and abundant portal venous gas, with displacement
and compression of intestinal loops to posterior and
inferior planes (Figures 1, 2, 3a, 3b). Laboratory tests
revealed significant leukocytosis and increased PCR.

Figure 3a. Axial computed tomography showing large dilated

stomach with signs suggestive of gastric pneumatosis and
displacement of small-bowel loops towards right flank.

Figure 1. Scout view showing severe dilated tubular structure

which extends from the left hypochondrium till the pelvic Figure 3b. Coronal reconstruction also depicting left kidney
excavation, along with signs suggestive of intrahepatic air. displacement.

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Figure 4. Image of overdistended stomach in supra- and

infra-umbilical open laparotomy.

Figure 6. Total gastrectomy specimen with signs of severe

vascular compromise at the level of gastric body and fundus.

Discussion
Gastric volvulus is a rare entity. By 2009 a publi-
cation documented that 350 cases had been reported
worldwide (1). Its first description was made in 1866 by
Berti, as a postmortem finding. Later, it was repeatedly
described during autopsies and surgeries. In 1921,
Rosselet reported the first case of chronic gastric
volvulus radiologically seen (2).
The peak incidence of gastric volvulus occurs
in the fifth decade of life, although some authors
speculate that it is higher in children (3). No significant
differences in prevalence by gender or race have
been found, although some authors have reported a
higher prevalence in females (4).
Gastric volvulus is defined as an abnormal rotation
Figure 5. Intraoperative view of stomach with mucosal signs of the stomach of more than 180 degrees, which can
of ischemia and necrosis at gastric fundus and body levels.
lead to obstruction of the gastric light, associated or not
to blood flow alteration. It may result in complications
such as gastric ischemia, necrosis and perforation,
Patient undergoes an extensive exploratory lapa- thus requiring rapid diagnosis.
rotomy evidencing an organo-axial volvulated stomach Predisposing risk factors have been identified, which
with transmural ischemic compromise of gastric body can be divided into idiopathic and secondary factors.
and fundus, in addition to a macroscopic perforation. Among idiopathic causes, elongation or absence of
Total gastrectomy and subsequent anastomosis ligaments that attach the stomach to the peritoneum
were performed (Figures 4, 5). stand out: gastrohepatic, gastrophrenic, gastrocolic,
and gastrosplenic ligaments. Furthermore, abnormally
Anatomopathologic testing of surgical specimen distended stomachs are more prone to rotate. Other
evidenced complete gastric piece with necrotic gastric associated anomalies are diaphragmatic hernias,
body and fundus along with macroscopic perforation eventration of the diaphragm, wandering spleen,
in the same area (Figure 6). and malrotation with asplenia (5). In a study of 500
Patient evolved satisfactorily from a medical pers- autopsies of patients with hiatus hernia, incomplete
pective and anastomosis was programmed. gastric volvulus was found in12 cases (6).

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Bariatric surgery, such as Nissen fundoplication, cases of paraesophageal hiatal hernia, diaphragmatic
gastric ligament ruptures post liver transplantation, eventration, trauma, diaphragmatic paralysis (phrenic
or trauma and gastric tumors are mentioned among nerve injury), among others (3).
secondary risk factors. Mesenteroaxial volvulus is rare. It occurs when
According to the direction of rotation, two types of stomach rotates on its minor axis, resulting in the dis-
volvulus may be found: organoaxial volvulus (58% of placement of the antrum above the gastroesophageal
cases) and mesenteroaxial volvulus (29% of cases). junction. This rotation is usually partial (less than 180
An estimated 2% of cases corresponds to mixed degrees) and not associated to diaphragmatic defects.
volvulus, remaining unclassified about 10%. In up There are also complex or mixed volvulus, with
to 70% of cases, gastric volvulus is associated with organoaxial as well as mesenteroaxial components,
diaphragmatic defects or pathology of the esophago- exhibiting low frequency, as reported in the literature.
gastric junction (Figure 7). The clinical presentation of gastric volvulus can be
acute or chronic. Acute volvulus may present clinically
with the triad of Borchardt: vomiting, epigastric pain
and an inability to pass an NGT, due to distortion of
anatomy at the gastroesophageal junction. Gastric
necrosis with fatal outcome may occur within hours
if not promptly resolved by surgery(5). Chronic pre-
sentation may be asymptomatic, its diagnosis being
usually incidental. It presents with upper abdominal
pain that may radiate to the back or shoulders, pain
during feeding or early post prandial discomfort, early
satiety and vomiting. In this case, symptomatology of
frequently associated diseases such as diaphragmatic
hernia and eventration of diaphragm may be found.
An accurate and timely diagnosis is of vital im-
portance, since patients prognosis will depend on it.
Side-up position of the stomach with pylorus
Figure 7. Scheme showing 2 types of rotation: Organoaxial cephalad to cardia, and a double air-fluid level are
(A) and Mesenteroaxial (B). radiological findings in mesenteroaxial volvulus. Fur-
thermore, diaphragmatic hernias containing antrum
and pylorus within may be found, wich constitutes
Organo-axial volvulus is most commonly seen the so called hook sign(8). Concerning organoaxial
in adults, associated to strangulation in 5-28% of volvulus, diagnosis is more difficult: stomach may be
cases. It occurs when the stomach rotates on its own observed horizontally located with lesser curvature
axis, or the line resultimg from joining pylorus with placed caudal to the greater curvature and presence
the gastroesophageal junction; greater curvature is of a single air-fluid level (Figures 8, 9). The oral barium
found cephalad whilst less curavature stays caudal fluoroscopic study confirms diagnosis and degree of
to its normal position, which constitutes a surgical obstruction, besides allowing observation of contrast
emergency. It is most commonly encountered asso- agent passage through partial volvulus as well as
ciated to trauma or paraesophageal hernias that alter accumulation of it in volvulus surrounding areas in the
the normal gastric position, manifested as complete complete entities. Computed Tomography ultimately
or partial volvulus. When volvulus is complete, i.e., provides a detailed anatomical view of the case, in
rotated greater than or equal to 180 degrees, obs- addition to describing the phenomenon complications
truction occurs and stomach dilates secondarily. among which gastric pneumatosis, portal venous gas
Conversely, if the volvulus is partial, i.e., rotated less and pneumoperitoneum are included (Figures 10, 11).
than 180, there may absence of obstruction, vascular There are isolated descriptions in literature about the
compromise or associated symptoms. In this case appearance of organoaxial volvulus on ultrasound
we can say that stomach has an organoaxial position sequences, visualized as a double dilation with central
rather than constituting an organoaxial volvulus as stricture, the so called peanut sign(9).
such. This position of stomach predisposes to future Management of gastric volvulus will depend
organoaxial volvulus; therefore, patient follow-up must mainly on its origin and presentation, whether acute
be indicated (7). or chronic. There are three pillars in its treatment: re-
In turn, organo-axial volvulus can be classified duction of the volvulus, gastric fixation and correction
into type 1 (primary) and type 2 (secondary). Type of predisposing factors.
2 is the most common presentation (2/3 of cases), Three surgical techniques have been described:
with supradiaphragmatic location; it is usually seen in laparotomy, laparoscopy and endoscopy(10).

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Figure 10. Computerized tomography section showing severe

gastric dilation, compression of liver parenchyma with portal
air, and displacement of retroperitoneal structures to right.

Figure 8. Coronal reconstruction of CT scan demonstrating

severely distended stomach, vertical distribution, with an
air-fluid level in addition to gastric pneumatosis and portal
venous air.

Figure 11. Computed tomography cut showing gastric

pneumatosis in pelvic excavation.

In 1968 Tanner describes various surgical

methods for repairing gastric volvulus involving
repair of diaphragmatic hernias, gastropexy, partial
gastrectomy for gastric necrosis, fundoantral gastro-
gastrostomy (Opolzers Operation), gastropexy with
gastrocolic ligament fixation (Tanners Operation),
gastrojejunostomy, and repair of diaphragmatic
hernias (11,12).
In preoperative high-risk patients, endoscopic
approach, i.e., performance of devolvulation via
endoscopic percutaneous gastrostomy, has shown
good surgical outcomes (13). Two techniques have
been described for devolvulation: Alpha-loop ma-
neuver described by Tsang et al in 1995, which
Figure 9. Sagittal reconstruction confirming same previous encompasses 6 steps: the initial aim is to create
findings. an alpha shaped loop in the proximal end of the

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volvulated stomach. Next, the tip of the endoscope

is advanced through the location of the stenosis
produced by the volvulus. The following three
steps aim to take the end of the endoscope to the
duodenum. Once there, clockwise torque is endos-
copically applied to complete the devolvulation (14).
J-maneuver, or retroversion, has also been used
to perform gastropexy.
Laparoscopic treatment has indications such as
reducing the volvulus, anchoring the gastric fundus
to the diaphragm, connecting the greater curvature
of the stomach to the abdominal wall, in addition to
some diaphragmatic repair. Laparoscopic technique
is indicated in patients with chronic volvulus where
neither necrosis nor gastric ischemia is observed.
Total gastrectomy is performed only in cases of
gastric necrosis.
Pathologic anatomy has a large surgical spe-
cimen in acute cases in which gastric necrosis is
detected intraoperatively, in which case a commonly
total gastrectomy is performed. This necrosis is
secondary to ischemia generated by two mecha- Figure 13. Pathological specimen demonstrating macroscopic
nisms: vascular obstruction as such, and intramural parietal perforation.
irrigation injury due to acute dilation (15).
Findings comprise necrosis of wall thickness
Conclusion
in the gastric area closest to the greatest site of
Gastric volvulus is a clinical entity with low fre-
vascular obstruction, mucosal and submucosal ne-
quency rates as well as discrete expression in world
crosis half-way to the same site, and inflammatory
literature, mainly appearing in case reports. There is a
infiltrate in more peripheral areas. Transmural
wide spectrum of this patologhy, ranging from chronic
microperforation and signs of inflammation and
presentation (underdiagnosed, with non-especific symp-
necrosis of vascular structures may also be found
toms) to acute entity with abrupt clinical presentation,
(Figures 12, 13).
ominous prognosis, with eventual outcome of death.
Mortality rates for this disease vary in different
The fundamental role of diagnostic radiologic
publications depending on statistical consideration
techniques is to provide guidance in detecting the
of chronic gastric volvulus and the type of surgery
presence, mechanism of occurrence, and entity-related
performed, ranging from 12 to 50% (16), rising to
complications in order to promote early diagnosis,
more than 80 % in cases where portal venous gas
adequate planning of therapeutic approach, as well
is present.
as reduction in morbi-mortality rates.

Acknowledgements
Dr. Alejandro Readi V., Specialist in Surgery,
Hospital del Salvador, Santiago, Chile.
Dr. Pablo Villegas, Pathologist Physician, Hospital
del Salvador, Santiago, Chile.

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