As with all organs in the body, the stomach has a set orientation. Most of the abdominal organs, especially the different parts of the digestive tract, have some degree of mobility. However, these minor changes in position are limited and usually does not change the orientation of the organ unless it is manually adjusted, like during surgery. Sometimes an organ can begin to rotate and become twisted. This type of condition is more commonly seen with the intestines (twisted bowel) but can also occur with the stomach.
What is gastric volvulus?
Gastric volvulus is also known commonly as a twisted stomach. It is a rare condition where the stomach rotates abnormally more than 180º. The twisting can occur on different planes. Apart from affecting normal movement through the stomach, a gastric volvulus can also cause the blood vessels supplying the stomach to become compressed. This can cut off the flow off blood and lead to a tissue death of the affected area of the stomach wall which in turn can progress to serious complications. Sometimes the stomach may tear.
With gastric volvulus being such an uncommon condition and presenting with symptoms similar to more common digestive conditions, it is sometimes missed in the early stages. About 10% to 20% of cases occur in children and gastric volvulus mainly arises before the age of 50 years. It affects both males and females equally. The cause of most cases of gastric volvulus is not known but it is associated with factors that allow for increased motion of the stomach from its normal position. If left untreated usually with surgery, the mortality rate may be as high as 80%.
Types of Gastric Volvulus
A gastric volvulus may be classified according to the way in which the stomach twists (the axis around which it twists) or by the cause of the volvulus. The first classification includes:
- Organoaxial type which accounts for almost 60% of all cases of gastric volvulus.
- Mesentroaxial type which accounts for about 30% of all cases of gastric volvulus.
- Combined type is a rare form where the stomach twists along both axes as the other two types.
The second classification according to cause includes:
- Type 1 which is idiopathic (unknown causes) and is the more common type that is mainly seen in adults.
- Type 2 which is due to congenital (from birth) or acquired (during life) factors and is mainly seen in children.
Causes of a Twisted Stomach
There is significant movement that occurs within the stomach. The strong muscles in the stomach wall contract and relax to mechanically breakdown food and aid with chemical digestion by mixing the food, digestive enzymes and stomach acid. These contractions can cause the stomach to move to a significant degree but it is prevented from doing so due to the proximity to neighboring organs, omentum and ligaments.
As discussed previously, type 1 gastric volvulus is the most common but occurs for unknown reasons (idiopathic). The stomach is held in position by several ligaments (gastrosplenic, gastroduodenal, gastrophrenic, and gastrohepatic ligaments). These ligaments have to maintain a certain degree of flexibility but also has to be relatively taut to maintain the stomach’s position in the abdominal cavity. It is believed that with type 1 gastric volvulus, the ligaments become abnormally lax.
With type 2 gastric volvulus there are congenital and acquired causes that allow for greater movement of the stomach. Congenital means that it is present from birth and is therefore often associated with structural abnormalities. Acquired means that it develops during the course of life. Some of the more likely causes include:
- Diaphragmatic defects since the diaphragm lies directly above the stomach.
- Gastric ligaments as discussed under type 1 gastric volvulus.
- Abnormal tissue like adhesions or bands that may attach to the stomach.
- Asplenism where the spleen is absent or underfunctioning thereby reducing support for the neighboring stomach.
Signs and Symptoms
A gastric volvulus may not always present with any major signs and symptoms depending on the degree of rotation. Sometimes the symptoms are subtle and often mistaken for other more common gastrointestinal ailments. Signs and symptoms of gastric volvulus include:
- Upper middle (epigastric) or left upper quadrant (LUQ) abdominal pain.
- Sometimes sharp chest pain radiating to the shoulder, neck, arm or back on the left side (may be mistaken for a heart attack or angina).
- Retching where a person vomits without expelling any gastric contents
- Abdominal distension that progressively worsens.
- Sometimes vomiting of blood occurs.
- Hiccups is a subtle sign in acute gastric volvulus.
The Borchardt triad indicates the three characteristic features of a gastric volvulus:
- Severe epigastric pain
- Retching without vomiting
- Inability to pass a nasogastric tube
The presence of these signs and symptoms should warrant further investigations to confirm the diagnosis of gastric volvulus. This may involve the following investigations:
- X-ray (plan and barium contrast)
- Computed tomography (CT scan)
- Upper gastrointestinal (GI) endoscopy
Complications of Gastric Volvulus
Severe cases of gastric volvulus particularly where prompt treatment is not forthcoming can lead to complications, some of which are p0tentially life-threatening.
- Strangulation where the blood supply to the stomach wall is cut off and this may lead to death of the stomach tissue (necrosis).
- Perforation where the stomach may tear usually at the necrotic area which is weak.
- Sepsis and cardiovascular collapse can follow a perforation.
Treatment for a Twisted Stomach
A gastric volvulus may be acute or chronic. Emergency surgery is necessary for an acute gastric volvulus. Surgery is also needed in chronic cases but it is usually done to prevent complications. Surgery involves relieving the twisted portion and may further involve repairing any defect that resulted in the volvulus. Medication may be prescribed for symptomatic relief in a gastric volvulus but cannot treat the underlying twisting. Surgery is the only option.
Gastric volvulus surgery may be done as an open or laparoscopically. The latter is minimally invasive compared to open surgery and there are fewer surgical complications. The mortality rate for gastric volvulus which was not diagnosed early and surgically treated was as high as 80%. However, advances in both diagnosis and treatment has greatly reduced the mortality rate. The complications for gastric volvulus surgery are similar to those of any other major abdominal surgery.