46.1 Introduction

  • Gastric volvulus is a rare clinical entity defined as an abnormal rotation of the stomach of >180°.

  • Berti was the first to describe gastric volvulus in a female autopsy patient in 1866.

  • In 1896, Berg performed the first successful operation for this condition.

  • In 1904, Borchardt described the classic triad associated with gastric volvulus:

    • Severe epigastric pain

    • Retching without vomiting

    • Inability to pass a nasogastric tube

  • Because many cases of chronic gastric volvulus are not diagnosed, the incidence and prevalence of gastric volvulus is unknown.

  • Gastric volvulus is generally considered rare in the pediatric age group.

  • Males and females are equally affected.

  • About 10–20% of cases occur in children, usually before the age of 1 year, but cases have been reported in children up to age 15 years.

  • Gastric volvulus in children is either:

    • Primary

    • Secondary to congenital diaphragmatic defects associated with intra-thoracic herniation of the stomach.

46.2 Etiology

  • The normal stomach is fixed and prevented from abnormal rotation by:

    • Four gastric ligaments (gastrosplenic, gastroduodenal, gastrophrenic, and gastrohepatic ligaments).

    • A normal diaphragm also serves to prevent abnormal displacement of stomach and gastric volvulus.

  • There are several conditions, both congenital and acquired, that lead to gastric volvulus. These include:

    • Congenital laxity of the anchoring ligaments

    • Congenital pyloric obstruction leading to chronic gastric dilatation

    • Congenital or acquired paraesophageal hernia

    • Congenital diaphragmatic hernias

    • Eventration of diaphragm

    • A tight wrap after Nissen’s fundoplication

    • Congenital asplenia

46.3 Classification

  • There are several classification systems for gastric volvulus.

  • The most frequently used classification system for gastric volvulus was proposed by Singleton.

  • This is based on the axis around which the stomach rotates (Figs. 46.1, 46.2, 46.3, and 46.4).

  • Singleton classified gastric volvulus into three types:

    • Organoaxial

    • Mesentericoaxial

    • Combined

  • Organoaxial gastric volvulus (Fig. 46.5):

    • In an organoaxial gastric volvulus, the stomach rotates around an axis that connects the gastroesophageal junction and the pylorus.

    • The gastric antrum rotates in a direction opposite to the fundus of the stomach.

    • This is the most common type of gastric volvulus, occurring in approximately 60% of cases.

    • It is usually idiopathic but can be associated with diaphragmatic defects.

    • This type can be complicated by strangulation and gastric necrosis.

  • Mesentericoaxial type (Figs. 46.6 and 46.7):

    • In mesentericoaxial gastric volvulus, the stomach rotates around an axis that bisects the lesser and greater curvatures.

    • The gastric antrum rotates anteriorly and superiorly so that the posterior surface of the stomach lies anteriorly.

    • The rotation is usually incomplete and occurs intermittently.

    • Strangulation and necrosis are uncommon.

    • Mesentericoaxial gastric volvulus comprises approximately 30% of cases of gastric volvulus.

    • Patients with mesentericoaxial gastric volvulus usually have chronic symptoms.

    • This type is not associated with diaphragmatic defects.

  • Combined type:

    • The combined type of gastric volvulus is a rare form in which the stomach twists both mesentericoaxially and organoaxially.

    • This type of gastric volvulus makes up about 10% of gastric volvulus cases.

    • It is usually seen in those with chronic volvulus.

  • Gastric volvulus is also classified according to etiology into:

    • Type 1 (primary, idiopathic)

    • Type 2 (secondary or acquired)

  • Type 1 gastric volvulus:

    • Idiopathic gastric volvulus is the commonest type, comprising two-thirds of all gastric volvulus cases.

    • It is idiopathic.

    • There is no definite cause but presumably it is due to abnormal laxity of the ligaments fixing and holding the stomach in place (gastrosplenic, gastroduodenal, gastrophrenic, and gastrohepatic ligaments).

  • Type 2 gastric volvulus:

    • Type 2 gastric volvulus is found in one-third of patients with gastric volvulus.

    • It is usually associated with congenital or acquired abnormalities that result in abnormal mobility of the stomach.

    • These abnormalities include:

      • Congenital diaphragmatic defects

      • Paraesophageal hernia

      • Eventration of diaphragm

      • Abnormal attachments, adhesions, or bands: 9%

      • Congenital asplenia: 5%

      • Small and large bowel malformations: 4%

      • Pyloric stenosis: 2%

      • Colonic distention: 1%

      • Rectal atresia: 1%

  • Rarely, gastric volvulus may be a complication of liver transplantation.

  • Gastric volvulus is also classified according to the site:

    • Intra-abdominal gastric volvulus

    • Intrathoracic gastric volvulus (Figs. 46.8 and 46.9)

  • Intrathoracic gastric volvulus is rare in children and is usually seen in children with diaphragmatic hernia and intrathoracic herniation of the stomach.

  • Intrathoracic gastric volvulus is a very serious condition that may lead to cardiopulmonary compromise from gastric distention (Fig. 46.10).

  • Gastric volvulus is also classified depending on the presentation into (Figs. 46.11, 46.12, 46.13, and 46.14):

    • Acute

    • Chronic

  • This depends on the degree of gastric twisting and the rapidity of onset.

  • While acute gastric volvulus is very rare, chronic gastric volvulus is being diagnosed with increasing frequency.

  • If not promptly diagnosed and treated, acute gastric volvulus can lead to strangulation, necrosis, and perforation of the stomach.

Figs. 46.1 and 46.2
figure 1

Diagrammatic representation of the axis around which the stomach rotates to form a gastric volvulus. The blue line represents the axis line. In an organoaxial gastric volvulus, the stomach rotates around an axis that connects the gastroesophageal junction and the pylorus. In mesentericoaxial gastric volvulus, the stomach rotates around an axis that bisects the lesser and greater curvatures

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Figs. 46.3 and 46.4
figure 2

Barium meal showing organoaxial gastric volvulus . Note the associated severe gastroesophageal reflux in the first one

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Fig. 46.5
figure 3

Barium meal showing organoaxial gastric volvulus

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Figs. 46.6 and 46.7
figure 4

Barium meal showing mesentericoaxial gastric volvulus

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Figs. 46.8 and 46.9
figure 5

Barium meal showing intrathoracic herniation of the stomach with gastric volvulus

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Fig. 46.10
figure 6

Chest x-ray showing acute gastric dilatation in a patient with intrathoracic stomach and gastric volvulus

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Figs. 46.11 and 46.12
figure 7

Chest x-ray showing left diaphragmatic hernia . Note also the double bubble shadow suggesting stomach herniation into the chest with possible gastric volvulus

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Figs. 46.13 and 46.14
figure 8

Barium meal showing organoaxial gastric volvulus with gastroesophageal reflux in the first one and left congenital diaphragmatic hernia with stomach herniation into the chest. Not the constriction of the stomach at the level of the diaphragmatic defect, which could represent gastric volvulus, as the gastroesophageal junction is at its normal position

Full size image
Figs. 46.15–46.17
figure 9

Barium meal studies showing chronic gastric volvulus . Note the associated gastroesophageal reflux in the first two films

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Fig. 46.18
figure 10

Postoperative barium meal in a child who had gastropexy for gastric volvulus. Note the normally oriented stomach

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46.4 Clinical Features

  • The clinical symptoms depend on the extent or degree of gastric rotation and obstruction.

  • Intermittent or chronic gastric volvulus may cause diverse gastrointestinal symptoms in children. This is one of the reasons for delayed diagnosis in these patients.

  • Gastric volvulus may present in either acute or chronic type.

  • The clinical features of chronic gastric volvulus are not specific, and the diagnosis is often delayed.

    Classification of Gastric Volvulus

    According to Type (Axis of Rotation)

    1. 1.

      Organoaxial

    2. 2.

      Mesentericoaxial

    3. 3.

      Combined

    According to Etiology

    1. 1.

      Primary

    2. 2.

      Secondary

    According to Site

    1. 1.

      Intra-abdominal

    2. 2.

      Intra-thoracic

    According to Presentation

    1. 1.

      Acute

    2. 2.

      Chronic

  • Chronic gastric volvulus should be suspected in children with a history of:

    • Chronic vomiting

    • Abdominal distension

    • Failure to thrive

    • Recurrent chest infection

  • Children with chronic gastric volvulus may also present with intermittent epigastric pain, recurrent attacks of vomiting, and abdominal fullness following meals.

  • This may be associated with upper abdominal fullness and distension.

  • Dysphagia may occur if the gastroesophageal junction is distorted.

  • Acute gastric volvulus is a surgical emergency because delay in diagnosis and treatment can cause strangulation, necrosis, and perforation of stomach.

  • Occasionally, some patients present with hematemesis.

  • This is secondary to mucosal ischemia and sloughing. This can rapidly progress to hypovolemic shock from loss of blood and fluids.

46.5 Diagnosis

  • The diagnosis of chronic gastric volvulus is difficult, and a high index of suspicion is important for early diagnosis and treatment.

  • In chronic gastric volvulus, abdominal radiograph may show:

    • Only gaseous dilatation of the stomach.

    • In mesentericooaxial volvulus, the gastric shadow may show double air fluid levels in the erect film, one in the fundus and the other in the antrum.

    • In organoaxial volvulus, the stomach lies horizontally with a single fluid level.

  • An upper contrast study is diagnostic in chronic gastric volvulus.

    • The stomach is rotated.

    • Absence of classical radiological signs may be observed in intermittent gastric volvulus.

    • An associated gastroesophageal reflux may be seen (Figs. 46.15, 46.16, and 46.17).

46.6 Treatment

  • Acute gastric volvulus is a surgical emergency.

  • Chronic volvulus should be initially treated conservatively:

    • Keep the patient in the prone position.

    • Giving small frequent feeds.

    • H2 blockers or proton pump inhibitors.

    • Prokinetics (Metoclopramide).

  • Overall, 40–60% of infants with chronic gastric volvulus who are treated conservatively do well with subsequent spontaneous improvement of symptoms, growth, and development.

  • Surgical treatment of chronic gastric volvulus remains controversial and limited to patients with:

    • Persistent or severe symptoms.

    • Repeated attacks of chest infection.

  • Gastropexy is the treatment of choice. This can be done as (Fig. 46.18):

    • Anterior gastropexy (fixing the anterior wall of the stomach to the anterior abdominal wall).

    • Fundal gastropexy (fixing the fundus of the stomach to the diaphragm).

    • Combined anterior and fundal gastropexy.

    • Combined anterior and fundal gastropexy without fundoplication is the preferred method.

  • This can be done using the classic open approach or laparoscopic approach.

  • Percutaneous endoscopic gastrostomy or laparoscopic-guided gastropexy have been used to treat chronic gastric volvulus.