Chronic gastric volvulus

Clinical History

A 65-year-old male patient presented to the emergency room with dyspnoea.

Imaging Findings

A 65-year-old male patient presented to the emergency room with dyspnoea. His chest X-ray scan showed an intra-thoracic air fluid level. The barium meal test results showed that he had a sliding hiatal hernia involving more than half the stomach with a 180º organo-axial torsion of the herniated segment but no obstruction in the herniated portion of the stomach. The greater curvature lies to the right and above the lesser curvature.

Discussion

Gastric volvulus is known to be an uncommon condition in which there is an abnormal degree of rotation of the stomach around itself, resulting in gastric obstruction. Berti first described gastric volvulus in 1866, after having performed the first successful operation on a patient with gastric volvulus in 1896. In 1904, Borchardt described the classic triad of severe epigastric pain, retching without vomiting, and inability to pass a nasogastric tube. Although the term gastric volvulus has been applied to abnormalities pertaining to the gastric position without there being any obstruction, Schatzki and Simeone stated that these anomalies, such as the “upside-down stomach” and large paraesophageal hernias, should not be classified as true volvulus unless there is an obstruction. These conditions of torsion, displacement, or chronic volvulus should be distinguished from acute volvulus where obstruction is present. As much as 180º of twisting may occur without there being any obstruction or strangulation of the blood supply. Twisting beyond 180º usually produces a complete obstruction with clinical manifestations of an acute condition within the abdomen. The stomach may rotate about its longitudinal axis—a line extending from the cardia to the pylorus— (organo-axial volvulus) or a line drawn from the mid-lesser to the mid-greater curvature (mesentero-axial volvulus). The former is more common and is often associated with a paraesophageal hiatal hernia. In other patients, eventration of the left diaphragm allows the colon to raise the stomach by pulling on the gastrocolic ligament. Acute gastric volvulus produces a severe abdominal pain accompanied by a diagnostic triad (Brochardt’s triad): a) vomiting followed by retching and then an inability to vomit, b) epigastric distension, and c) inability to pass a nasogastric tube. This may result in mucosal ischaemia with areas of focal necrosis that permit gas to dissect into the gastric wall, producing intramural emphysema. Perforation may result from full thickness necrosis. The large, distended stomach resulting from volvulus is easily recognised on abdominal radiographs. It may extend up into the chest because of diaphragmatic eventration or hernia that may be present. The situation calls for immediate laparotomy to prevent death from acute gastric necrosis and shock. An emergency upper gastrointestinal series will show a block at the point of the volvulus. The death rate in these cases is high. The differential diagnosis includes gastric atony, acute gastric dilatation, and pyloric obstruction. In these conditions, there is no delay in the passage of barium into the stomach which has a normal configuration. Chronic volvulus is more common than acute volvulus. It may be asymptomatic or may cause crampy intermittent pain. Patients typically present with an intermittent epigastric pain and abdominal fullness following meals. Patients may report early satiety, dyspnoea, and chest discomfort. Dysphagia may occur if the gastroesophageal junction is distorted. Because of the non-specific nature of the symptoms, however, patients are often investigated for other common disease entities such as cholelithiasis and peptic ulcer disease. An upper GI series can be of diagnostic value during an acute attack. Cases associated with paraesophageal hiatal hernia should be treated by repair of the hernia and anterior gastropexy. When cases are due to eventration of the diaphragm, the gastrocolic ligament should be divided along the entire length of the greater curvature. The colon rises to fill the space caused by the eventration, and the stomach will resume its normal position, to be fastened by doing a gastropexy. When the anatomic attachments of the stomach are considered, it is surprising to note that gastric volvulus occurs at all. It seems to require unusually long gastrohepatic and gastrocolic mesenteries. Abnormalities of the four suspensory ligaments of the stomach (hepatic, splenic, colic, and phrenic) are probably the most frequent causes of volvulus. Most of the reported cases have been associated with diaphragmatic abnormalities, such as eventration or hiatus hernia. About one-third of the cases are associated with hiatus hernia, usually of the giant paraesophageal type.

Differential Diagnosis List

Final Diagnosis

Chronic gastric volvulus.

URL:	https://www.eurorad.org/case/3323
DOI:	10.1594/EURORAD/CASE.3323
ISSN:	1563-4086