What are the symptoms and treatment options for gastric volvulus, particularly in patients with underlying conditions such as hiatal hernia or gastrointestinal motility disorders?

Gastric Volvulus: Symptoms and Treatment

Clinical Presentation

Gastric volvulus presents with the classic Borchardt triad: severe epigastric pain, intractable retching with inability to vomit, and failure to pass a nasogastric tube, though this complete triad is uncommon. 1, 2

Acute Presentation

• Severe abdominal pain (typically epigastric) with sudden onset, often following a large meal 1
• Intractable vomiting or retching that may progress to inability to vomit as obstruction worsens 1, 2
• Marked epigastric distension with tenderness on examination 2
• Upper gastrointestinal bleeding manifesting as coffee-ground emesis or hematemesis due to mucosal ischemia 2
• Inability to pass nasogastric tube due to gastric outlet obstruction 1
• Severe dehydration and potential shock if presentation is delayed 2

Chronic Presentation

• Recurrent vomiting attacks (most common symptom, present in 83% of pediatric cases) 3
• Recurrent chest infections and asthma-like symptoms due to aspiration 3
• Failure to thrive in children, weight loss in adults 3
• Intermittent epigastric pain and early satiety 3
• Choking with feeds in infants 3

Associated Conditions

• Hiatal hernia is the most common underlying cause, present in the majority of cases 4, 2
• Ligamentous laxity is the principal predisposing factor 4
• Gastroesophageal reflux is demonstrable in 97% of chronic cases 3

Diagnostic Approach

Imaging Studies

• Chest X-ray shows a high air-fluid level in the chest or upper abdomen, which should immediately raise suspicion 4, 2
• CT scan is now the gold standard, providing comprehensive visualization of stomach position, rotation axis, and critically, assessment of gastric wall viability 4
• Barium swallow confirms the diagnosis and defines the type of volvulus (organoaxial versus mesentericoaxial), though CT has largely replaced this 4

Classification

• Organoaxial volvulus (most common): stomach rotates along its long axis from cardia to pylorus 3, 4
• Mesentericoaxial volvulus (rare): rotation perpendicular to the gastroesophageal axis 3, 4

Treatment Algorithm

Acute Gastric Volvulus (Life-Threatening Emergency)

Immediate surgical intervention is mandatory for acute gastric volvulus due to high risk of gastric ischemia, necrosis, and perforation. 1, 4, 5

Surgical Approach

• Laparoscopic surgery is the preferred approach when feasible, with superior postoperative outcomes, fewer complications (20% versus 75% in open surgery), and better quality of life 5
• Emergency laparotomy is required if patient is hemodynamically unstable, has peritonitis, or when laparoscopic expertise is unavailable 5, 2

Surgical Steps

1. Reduction of the volvulus and decompression of the stomach 4, 5, 2
2. Assessment of gastric viability - if necrosis is present, gastric resection is necessary 1, 4
3. Reintegration of stomach into abdominal cavity if intrathoracic migration has occurred 4, 2
4. Repair of hiatal hernia if present (most cases) 4, 2
5. Gastropexy (both anterior to abdominal wall and fundal to diaphragm) to prevent recurrence 3, 5, 2
6. Nissen fundoplication may be performed to address associated gastroesophageal reflux and prevent recurrence 2

Chronic Gastric Volvulus

Treatment depends on symptom severity - mild to moderate symptoms warrant conservative management, while persistent severe symptoms require elective surgical repair. 3

Conservative Management (Mild-Moderate Symptoms)

• Medical management with proton pump inhibitors and prokinetic agents for patients with minimal symptoms 3
• Close monitoring for symptom progression 3

Surgical Management (Severe/Persistent Symptoms)

• Elective laparoscopic repair is preferred, offering excellent outcomes with minimal morbidity 5
• Anterior and fundal gastropexy without fundoplication is the recommended procedure for chronic cases 3
• Hiatal hernia repair if present 4

Critical Pitfalls to Avoid

• Do not delay diagnosis - acute gastric volvulus can rapidly progress to gastric necrosis and perforation with mortality rates approaching 30-50% if untreated 1, 4
• Do not attempt nasogastric decompression alone in acute cases - this is a surgical emergency requiring operative intervention 1, 4
• Do not miss the diagnosis in patients with atypical chest pain - gastric volvulus can mimic cardiac or pulmonary pathology 3, 2
• Do not perform gastropexy alone without addressing the hiatal hernia - failure to repair the hernia leads to recurrence 4, 2
• In pediatric cases, do not overlook chronic volvulus in children with recurrent vomiting, chest infections, or failure to thrive - barium studies should be part of the workup 3

Postoperative Outcomes

• Laparoscopic approach results in 80% patient satisfaction with excellent quality of life scores at median 25-month follow-up 5
• Recurrence after proper surgical repair with gastropexy is rare (20% in one series), occurring primarily when hiatal hernia repair is inadequate 5
• Mortality for emergency surgery ranges from 0-30% depending on presence of gastric necrosis and patient comorbidities 1, 4