Introduction
The stomach is an important muscular organ of the digestive system in the human body. It is located on the left side of the upper part of the abdomen. Sometimes, the stomach undergoes twisting that changes the shape and location of the stomach. This is a rare clinical condition characterized by rotation of the stomach by more than 180 degrees.
The stomach can rotate or twist around the organoaxial and mesenteroaxial planes, which means that the stomach can rotate on the transverse or longitudinal axis. Gastric volvulus can occur in any age group, but acute gastric volvulus is more common in infants (babies younger than one-year-old) and older adults.
What Is Gastric Volvulus?
It is a rare condition in which the stomach rotates 180 degrees transversely or longitudinally. Acute gastric volvulus is a surgical emergency associated with an interrupted blood supply, and chronic gastric volvulus is generally associated with less specific symptoms. The symptoms are not visible in the early stages.
What Is the Classification of Gastric Volvulus?
Gastric volvulus can be of different types based on the rotation:
1. Organoaxial Gastric Volvulus: It is the most common type, seen in 60% of cases. It occurs when the stomach is rotated in the longitudinal axis connecting the esophagogastric junction - a muscle in the distal ends of the esophagus - and the pylorus. The stomach appears upside down.
2. Mesenteroaxial Gastric Volvulus: It is a less common type, seen in 30% of cases. It occurs when the stomach is rotated in the transverse plane or axis.
3. Combined Gastric Volvulus: It occurs when the stomach is rotated both organoaxial and mesenteroaxially.
Gastric volvulus can be of different types based on the cause:
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Primary Gastric Volvulus: It occurs because of primary causes such as loosening of the ligaments present in the stomach. It is seen below the diaphragm.
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Secondary Gastric Volvulus: It is more commonly seen in children and occurs because of secondary causes such as abnormalities in the anatomy of the abdomen. For example, defects in the diaphragm and is seen above the diaphragm.
What Causes Gastric Volvulus?
Most commonly, gastric volvulus is caused by:
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Diaphragmatic Dysfunction - A type of anatomic disorder resulting in complete or partial muscle paralysis of the diaphragm. It is the most common cause of gastric volvulus. For example, a hernia of the diaphragm.
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Gastric or Stomach Disorder - Disease of the stomach that affects the gastrointestinal tract. For example, vomiting, nausea, etc.
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Splenic or Spleen Disorder - Dysfunctioning of the spleen, such as a condition in which the red blood cells are destroyed by the spleen abnormally or bacterial infection of the spleen.
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Disturbances in the ligaments and attachments of the stomach.
What Are the Gastric Volvulus Symptoms?
The commonly occurring symptoms are:
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Sudden and severe pain in the upper abdomen or lower part of the chest.
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Reverse movements of the stomach and esophagus without vomit - retching or dry heaves.
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Cyanosis (bluish color of the hands because of low oxygen levels).
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Hematemesis (vomit blood).
Sometimes the symptoms are mild and/or not specific, indicating chronic gastric volvulus, such as:
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Dysphagia - Difficulty swallowing.
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Epigastric Pain and Discomfort - Pain in the area below the ribs or above the abdomen.
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Bloating - Feeling of fullness in the stomach due to gas.
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Heartburn - Heartburn is the feeling of burning chest after eating food.
How to Diagnose Gastric Volvulus?
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Physical Examination: The doctor may find the presence of severe pain in the patient's upper abdomen. Because of the retching, the doctor cannot pass the nasogastric tube. This occurs as a result of obstruction created by the gastric volvulus, which is called Borchardt's triad.
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Imaging Test: An X-ray or computed tomography or CT scan is performed to confirm the gastric volvulus. The X-ray may show a gas-filled structure in the chest. Sometimes, an X-ray of the upper gastrointestinal tract may show a hernia of the diaphragm. Computed tomography provides detailed information about the nature and type of volvulus.
What Is Gastric Volvulus Treatment?
Immediate surgery to untwist the volvulus is the gold standard approach.
1. Gastric Decompression: Nasogastric or orogastric decompression is the first step before surgery. In this process, a nasogastric tube is inserted, and the contents of the stomach are drained out, such as fluids. After this, the stomach is decompressed and provides control over vomiting.
2. Laparoscopic or Open Reduction: Most commonly, open surgical reduction is performed. In this procedure, the volvulus is reduced with the help of an endoscope - a thin tube with a light camera is inserted to view the internal structure and organs within the human body. The images are displayed on a monitor screen that guides the doctor in identifying the exact location of the disease or abnormality. The open reduction technique is sometimes replaced with the laparoscopic reduction technique because it is less invasive and has a lesser recovery time. In this technique:
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General anesthesia is given to the patient.
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The patient is placed in an inverted Y position.
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Vital signs of the patient are monitored and maintained.
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The camera port is placed between the patient's legs.
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The abdominal cavity is assessed, and the abnormality is identified.
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After identifying the abnormality, gastric volvulus reduction is performed.
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The normal anatomy of the stomach is achieved.
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Percutaneous endoscopic gastronomy (PEG) tubes are inserted, for example, into the anterior or front part of the stomach if there is mesenteroaxial gastric volvulus, and endoscopic images are taken to confirm the complete removal of the obstruction. These tubes prevent the recurrence of the gastric volvulus.
3. Gastropexy: In this procedure, the stomach is attached to the wall of the abdomen to prevent the recurrence of the gastric volvulus. It can be done with three techniques - endoscopic, laparoscopic, and combined approach.
Endoscopic Gastropexy:
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Gastric volvulus reduction is the first step in which the gastroesophageal junction is advanced, and the stomach is filled or blown with air - insufflation. This process reduces the stomach.
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Multiple percutaneous endoscopic gastronomy (PEG) tubes are inserted one by one with a distance of 12 cm between them.
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PEG tubes also provide nutritional supplication directly into the stomach - enteral nutrition and medication administration.
Laparoscopic Gastropexy:
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The gastric volvulus is reduced manually, and the stomach is attached to the abdominal wall with suturing.
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This fixation is generally one or two points. Nowadays, multiple fixation points are made to prevent recurrence and provide firm fixation of the stomach. It means multiple sutures are made along the stomach curvature.
Laparoendoscopic Gastropexy:
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Multiple ports of 5 mm are placed into the abdomen.
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Laparoscopy is performed with the help of these ports, after which PEG tubes are inserted with direct visualization.
What Are the Complications of Gastric Volvulus?
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Ulcerations - These are open sores formed because of loss of skin.
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Perforations - A hole or puncture that develops on the wall or lining of the stomach.
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Hemorrhage - Excessive internal bleeding.
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Pancreatic Necrosis - Absence of blood supply to the pancreas resulting in tissue death or necrosis.
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Omental Avulsion - Tearing of a large fat tissue (omentum) hanging down from the stomach.
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Splenic Rupture - It is a rupture of the spleen because of disturbed blood supply to the spleen.
Conclusion:
Gastric volvulus, especially acute type, is a medical or surgical emergency that requires immediate surgical treatment. This condition occurs rarely but is serious and presents with non-specific clinical signs and symptoms that are difficult to identify and diagnose. Reducing the stomach to untwist the volvulus is a good standard approach that can be performed through endoscopy, laparoscopy, or combining both. The treatment shows good outcomes, and the mortality rate is up to 20%.
