Twisted Stomach (Gastric Volvulus) Types, Causes, Diagnosis, Treatment

The organs within the human body lie in a particular orientation. This fixed orientation is determined by the developmental processes that occur within the fetus. Despite the fixed orientation, many organs within the abdomen have a certain degree of mobility. Minor changes in position of abdominal organs do not change their developmentally determined orientation. However, in some cases, an organ may twist and rotate to lie in an orientation that is not normal. Such twisting is frequently seen in the case of intestinal segments, and is referred to as volvulus.

What is gastric volvulus?

In some rare circumstances, the stomach may also twist and rotate into an abnormal orientation (sometimes more than 180 degrees). This condition is referred to as gastric volvulus or twisted stomach. The twisting of the stomach can occur in different planes. A twisted stomach adversely affects the movement of food through the stomach. It can also cause compression of nearby blood vessels, thereby choking blood supply to the stomach. The lack of blood supply can then lead to the death of the affected tissue areas in the stomach. Further serious complications include stomach tears.

Gastric volvulus is a very uncommon condition. Also, its symptoms may be mistaken for symptoms caused by some common digestive problems. This can lead to misdiagnosis and ineffective treatment efforts. Gastric volvulus can occur in both males and females. This condition usually occurs before the age of 50 years. Only about 10-20% of the cases of gastric volvulus are in children.

The cause of gastric volvulus is not clear in most cases. However, different factors that allow an increased movement of the stomach are associated with the condition. In the absence of surgical treatment, gastric volvulus has a high mortality rate (about 80%).

Types of Gastric Volvulus

Cases of gastric volvulus can be classified in two ways. One way is to classify gastric volvulus based on the axis around with the stomach twists. Another way is to classify gastric volvulus based on the underlying cause.
Gastric volvulus can be classified into the following three categories based on the type of stomach twists involved:

  1. Organoaxial type: About 60% of the cases of gastric volvulus are of the organoaxial type.
  2. Mesenteroaxial type: About 30% of the cases of gastric volvulus are of the mesenteroaxial type.
  3. Combined type: Cases with combined type of gastric volvulus (involving both organoaxial and mesenteroaxial twisting) are rare.

Gastric volvulus can be classified into the following two categories based on the cause of the twisted stomach:

  • Type I: Type I gastric volvulus has no known cause (idiopathic). It is the most common type of gastric volvulus, and is seen mostly in adults.
  • Type II: Type II gastric volvulus can either be present since birth (congenital) or acquired during later life. Type II gastric volvulus is seen mostly in children.

Signs and Symptoms

The signs and symptoms of gastric volvulus depend on the extent of rotation of the stomach. Some cases may be asymptomatic. Other cases may be characterized by subtle symptoms that might be mistaken for symptoms of other common gastrointestinal problems. The following are some of the signs and symptoms that may occur with gastric volvulus:

  • Abdominal pain may occur in the upper left or upper middle quadrant.
  • A sharp pain may be perceived in the chest. The pain may also radiate to other areas such as the left shoulder, arm, neck, and back regions. This pain may be mistaken for angina or heart attack.
  • Retching (without expulsion of any gastric contents) may occur.
  • Bloody vomit may also occur in some cases.
  • A progressively worsening abdominal distension may be seen.
  • Acute gastric volvulus may be accompanied by hiccups.

Read more on stomach knots.

Causes of Gastric Volvulus

The stomach is not a passive organ. The muscles of the stomach wall undergo rhythmic contraction and relaxation in order to break down the food. Apart from this mechanical churning of food, chemical and enzymatic digestion of food also occurs within the stomach.

The strong digestive contractions can cause significant movement of the stomach inside the abdominal cavity. However, the stomach is normally held in place by many different types of ligaments (such as gastroduodenal, gastrosplenic, gastrohepatic, and gastrophrenic ligaments). These ligaments allow a certain degree of flexibility, but are taut enough to prevent the stomach from twisting.

Type I (idiopathic) gastric volvulus is believed to occur when the ligaments holding the stomach in place become abnormally lax. Type II gastric volvulus (congenital and acquired) may occur due to structural abnormalities that allow greater movements of the stomach. In congenital gastric volvulus, these structural abnormalities may be present since birth. The following are some of the potential causes of type II gastric volvulus:

  • Defects in the diaphragm muscle may allow the stomach to move significantly.
  • Gastric ligaments that hold the stomach in place may be lax.
  • An under-functioning or absent spleen (asplenism) may provide more space for the stomach to move and twist.
    Abnormal bands and adhesions may also cause twisted stomach.

Diagnosis for Gastric Volvulus

Gastric volvulus is characterized by three main features that are collectively known as the Borchardt triad:

  • Severe pain in the epigastric region of the abdomen
  • Retching that occurs without any vomiting of the gastric contents
  • Inability to pass a nasogastric tube into the abdomen

When the Borchardt triad is present, investigations using X-ray (both plain and barium contrast), CT scan, and endoscopy of the upper gastrointestinal tract may be done to confirm the occurrence of twisted stomach.

Treatment for Gastric Volvulus

The main treatment for gastric volvulus is surgical correction. Medications may be prescribed to provide relief from the symptoms. In acute cases, surgery is an immediate requirement. In chronic cases of gastric volvulus, surgery is done to prevent serious complications.

Surgical treatment aims to correct the twisted region of the stomach, and also repair any defects that may have been caused by the twisting of the stomach. Both open surgery or laparoscopic surgery options are available. Laparoscopic surgery is the minimally invasive option that also causes fewer complications. The mortality rate in undiagnosed and untreated patients is as high as 80%.

Complications of Gastric Volvulus

Potentially lethal complications may arise if gastric volvulus is not treated promptly. The following are some of the potential complications:

  • Necrosis of the stomach tissue can occur if the blood supply to the stomach ceases due to compression of the blood vessels that supply the stomach.
  • Tears or perforations may appear in the necrotic areas of the stomach.
  • Perforation of stomach may be followed by sepsis and cardiovascular collapse.

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