Definition – Gastric volvulus can be defined as an abnormal rotation (>180o) of the stomach along its longitudinal axis (organoaxial Fig. 1 ) or through a short axis which joins the mid lesser and great curvatures (mesenteroaxial Fig. 2 ) .
Sometimes mixed findings of both types can be present.
The result is a closed loop obstruction which can lead to incarceration and strangulation.
The following ischemia and necrosis result in perforation and peritonitis,
with a potentially fatal outcome.
The first reported case in adults dates back to 1866 (Berti) [1],
and it was first described in children in 1899 (Oltimo) [2].
The first radiologic description was published in 1923 (Rosselet)[3].
According to a review of the literature published in 2008 [4],
581 cases of this entity had been reported,
making it somewhat more common than previously described.
Four ligaments stabilize the stomach in the peritoneal cavity: gastrocolic,
gastroesplenic,
gastrohepatic and gastrophrenic.
Agenesia,
elongation or disruption of these structures (particularly the gastrocolic and gastroesplenic ligaments [5]),
either congenital or acquired (i.e instrumentation,
trauma) results in abnormal mobility of the stomach.
Aditional stabilization is provided by the pylorus and the gastroesophageal junction.
The organoaxial type Fig. 3 Fig. 4 Fig. 5 Fig. 6 Fig. 7 is most commonly related with primary causes [5].
Secondary gastric volvulus are associated with congenital diaphragmatic and/or paraesophageal hernias or wandering spleen.
Secondary volvulus are mainly of the mesenteroaxial type Fig. 8 [5].
Clinical findings are related with the degree of gastric rotation and subsequent obstruction.
Both acute and subacute/chronic forms have been described[2].
Chronic volvulus have nonspecific symptoms (abdominal pain,
gastric distension,
vomiting) and may cause self-limited episodes until it becomes acute and irreversible[5].
Acute manifestations of disease include severe epigastric distension and intractable nausea or vomiting.
These symptoms,
along with the inability to pass a nasogastric tube,
constitute the so-called Borchardt triad [1] in adult patients.
However,
various reports in the literature report success in the placement of a nasogastric tube in children with volvulus [5].
Acute vegetative symptoms with hypotonia,
pallor and ocular revulsion can also be present and are believed to be caused by direct parasympathetic nervous stimulation[5].
There are no specific laboratory tests to confirm or suggest this diagnosis [1].
Elevation of serum amylase and alkaline phosphatase have been reported in association with volvulus,
but are neither sensitive nor specific and can mislead the diagnostic investigation and delay the treatment.
Imaging plays a major role in establishing the diagnosis of gastric volvulus,
even more so in the setting of an acute volvulus which is a true surgical emergency [3] that requires prompt intervention.
The aim is to reduce the volvulus and correct any predisposing factors,
usually including a gastropexy [2],
isolated or in combination with other techniques,
such as pyloromytomy or Nissen fundoplication [4].