Clinical History
A 64-year-old female patient presented with abdominal pain and vomiting.
Imaging Findings
A CT of the thorax and abdomen demonstrated distension of the stomach, gastric fundus being located under the left hemidiaphragm, and displacement and twisting of the body and antrum at the mesenteric axis through the diaphragmatic hernia into the left hemithorax. The nasogastric tube was placed with the distal tip in the fundus. The features are in keeping with incomplete mesenteroaxial gastric volvulus.
Discussion
The gastric volvulus is described as more than 180º rotation of the stomach resulting in obstruction. [1, 6]
It is most common in the fifth decade with equal sex distribution. [2, 7]
Berti reported the first case of gastric volvulus in 1866. Berg performed the foremost successful operation in 1897. [1]
Primary gastric volvulus occurs in 30% of cases as a result of gastric ligament insufficiency. 70% of cases were secondary volvulus due to abdominal adhesion, diaphragmatic hernia or paralysis of phrenic nerve. [3]
Based on the axis of rotation, gastric volvulus can be divided into 3 groups. The organoaxial volvulus is the most frequent form (59%) where the stomach rotates along its long axis. In mesenteroaxial volvulus, the stomach rotates along the transgastric axis leading to overlapping of the anterior gastric wall (29%). The third group (12%) may have characteristics of both mesenteroaxial and organoaxial volvulus or is unclassified. [1]
Clinical presentation can be acute volvulus with complete obstruction or could be intermittent and chronic with incomplete obstruction. [2]
The key symptoms include vomiting, severe epigastric pain with distention, and failure of nasogastric tube insertion, attributed as the Borchardt’s triad. [1]
In cases of mesenteroaxial volvulus, the rounded contour of the stomach can be seen on supine abdominal radiographs. The erect radiographs display double air fluid level with normally located gastric fundus on the left and inferior position, and the shifted antrum on the right and superior location. [1]
Barium studies reveal abrupt termination of the gastric or oesophageal barium column, abnormal whirling of the mucosal folds, and morphology of the intrathoracic gastric component. [2, 4] In organoaxial rotation, the greater curvature is seen superior to the lesser curvature. In mesenteroaxial rotation, the pylorus is visualised superior to the gastro-oesophageal junction. [1]
A CT scan can provide more accurate immediate diagnosis showing a twisted distended stomach, site(s) of torsion and ischaemia. [5]
Conservative treatment can be useful in mesenteroaxial volvulus with no significant obstruction of the cardia. An upper gastrointestinal endoscopic study can be valuable to assess the gastric mucosa as well as could be therapeutic in untwisting the gastric volvulus. [1]
Surgical management consists of hernia content reduction, de-rotation of the volvulus, hernial defect repair and internal fixation. Laparoscopic anterior gastropexy has been widely performed to manage acute and chronic gastric volvulus. [2]
Missed or delayed diagnosis of the gastric volvulus may result in haemorrhage, ischaemia and perforation. Prompt diagnosis and early treatment is essential. [1]
Differential Diagnosis List
Incomplete mesenteroaxial gastric volvulus
Organoaxial gastric volvulus
Paraoesophageal hernia
Final Diagnosis
Incomplete mesenteroaxial gastric volvulus
