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Emergency Medicine News:
doi: 10.1097/01.EEM.0000398869.72134.2c
Volvulus

A Case of Organoaxial Gastric Volvulus

McGrane, Owen MD; McGrane, Karen MD

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A 26-year-old active-duty man presents with acute onset abdominal pain with nausea, bloating, and excessive belching. He has a six-month history of episodic abdominal cramping, diarrhea, and melena. These intermittent paroxysms of abdominal pain are associated with a difficulty tolerating his diet and a 19-pound weight loss over the previous six months. Episodes are typically severe enough to debilitate him for several hours at a time, and have been gradually worsening.

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The patient has had numerous imaging exams — endoscopy, colonoscopy, and abdominal x-rays — and has been evaluated extensively by the gastroenterology service, carrying a diagnosis of irritable bowel syndrome. He denies heartburn, reflux, regurgitation, dysphagia, anorexia, or early satiety. The patient has been taking anti-diarrheals, antispasmodics, and proton pump inhibitors without relief. He has no other past medical history, and has never had abdominal surgeries.

He has no known familial inflammatory bowel disease or gastrointestinal cancer. The patient does not smoke or chew tobacco, drinks alcohol in moderation, and denies regular use of aspirin, acetaminophen, over-the-counter NSAIDs, and herbal products.

On physical exam, he was alert and oriented, and had abdominal pain but no acute distress. Heart and lung exams were normal. His abdomen was soft, nontender to palpation, not distended, and with active bowel sounds, most prominent in the left upper quadrant. Previously normal laboratories included TSH, stool culture, and O&P; a screen for celiac disease was negative. Initial studies included a normal CBC and serum chemistries, and he was negative for fecal occult blood. After double-contrast upper GI series and small bowel follow-through, the diagnosis was found: organoaxial gastric volvulus.

Gastric volvulus is a rare condition in which the stomach twists on itself, causing a closed-loop obstruction. There are two types, organoaxial and mesenteroaxial. Organoaxial volvulus is the more common type, representing approximately 60 percent of cases. Organoaxial volvulus occurs when the stomach rotates 180 degrees around the long axis. A diaphragmatic hernia is frequently associated with this condition.

Symptoms are typically acute in onset, and gastric ischemia is a potential complication. In mesenteroaxial volvulus, the stomach rotates around its short axis. This type of volvulus is more likely to be incomplete and intermittent with chronic symptoms.

The overall mortality of gastric volvulus has been estimated to be between 15 percent and 20 percent. Peak incidence occurs in the fifth decade of life. It may occur in children under a year old, and is typically associated with a congenital diaphragmatic defect. The incidence of this condition is unknown due to its intermittent nature, and many cases go undiagnosed.

Patients presenting with gastric volvulus typically complain of acute onset of upper abdominal pain, distention, and vomiting. The symptoms referred to as Borchardt's triad include sudden onset of severe upper abdominal pain, recurrent retching with production of little vomitus, and inability to pass a nasogastric tube. These symptoms should raise clinical suspicion for gastric volvulus. Hematemesis may be present in cases of esophageal injury related to retching or with associated gastric mucosal ischemia. In cases of chronic volvulus, patients may present with nonspecific symptoms such as epigastric discomfort, bloating, dysphagia, and dyspepsia after meals.

Plain films may demonstrate a gas-filled loop of bowel in the abdomen or chest. Barium swallow will confirm the diagnosis with visualization of the abnormality. There are no specific laboratory abnormalities associated with this condition.

Gastric volvulus is considered a surgical emergency. Treatment of gastric volvulus includes decompression of the stomach with a nasogastric tube, if possible. Endoscopic detorsion can be attempted if there are no signs of gastric infarction. Surgical detorsion with fixation of the stomach to prevent further episodes is the definitive treatment.

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Resources:

Drs. McGrane and McG...
Drs. McGrane and McG...
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Feldman M, Friedman LS, Brandt LJ. Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 9th ed.; Ch. 24: Abdominal Hernias and Gastric Volvulus. Philadelphia: Elsevier; 2010.
Marx JA, et al. Rosen's Emergency Medicine, 7th ed.; Ch. 87: Esophagus, Stomach, and Duodenum. Philadelphia: Elsevier; 2010.
Townsend CM, et al. Sabiston Textbook of Surgery, 18th ed.; Ch. 47: Stomach: Other Gastric Lesions. Philadelphia: Saunders; 2010.

© 2011 Lippincott Williams & Wilkins, Inc.

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