Gastric volvulus is uncommon, with its acute form progressing rapidly and being difficult to diagnose, often leading to delayed treatment. The chronic form has atypical symptoms and is also hard to detect promptly, making it essential to have a concise understanding of gastric volvulus.

bubble_chart Etiology

Neonatal gastric volvulus is a congenital malformation, possibly associated with malrotation of the small intestine, leading to laxity of the gastrosplenic ligament or gastrocolic ligament and resulting in poor gastric fixation. Most cases can self-correct as the infant grows and develops.

Adult gastric volvulus often involves anatomical factors that, under various triggers, lead to the condition. The normal position of the stomach primarily relies on fixation at the lower esophagus and the pylorus, with the hepatogastric ligament, gastrocolic ligament, and gastrosplenic ligament also contributing to the fixation of the greater and lesser curvatures. Larger hiatal hernias, diaphragmatic hernias, diaphragmatic eventration, and excessive laxity of the peritoneal membrane lateral to the descending duodenum make it difficult to fix the lower esophagus at the hiatus and the pylorus. Additionally, conditions such as gastric ptosis and laxity or elongation of the ligaments along the greater and lesser curvatures are anatomical factors contributing to gastric volvulus.

Acute gastric dilation, acute colonic distension, overeating, severe vomiting, and reverse peristalsis of the stomach can act as forces that abruptly alter the stomach's position, often serving as triggers for acute gastric volvulus. Inflammation and adhesions around the stomach can pull the gastric wall, fixing it in an abnormal position and causing volvulus. These pathological changes are often the triggers for chronic gastric volvulus.

Acute gastric volvulus has a sudden onset and rapid progression, with clinical manifestations quite similar to those of acute abdominal conditions such as ulcer perforation, acute pancreatitis, and acute intestinal obstruction, and is sometimes difficult to distinguish from acute gastric dilatation. The onset is always marked by sudden, severe upper abdominal pain that radiates to the back. It is often accompanied by frequent vomiting and belching, with no bile present in the vomitus. If the obstruction is in the proximal stomach, retching occurs. At this point, attempts to insert a gastrointestinal decompression tube often fail. Physical examination reveals distension in the upper abdomen while the lower abdomen remains flat. In cases of complete volvulus with proximal gastric obstruction, the typical presentation includes the aforementioned upper abdominal distension, retching, and inability to insert a gastric tube. If the volvulus is mild, the clinical manifestations are highly atypical. Abdominal X-ray plain films often show an enlarged stomach shadow filled with gas and fluid. Since barium cannot be ingested, gastrointestinal X-ray examinations are generally of little help in the acute phase, and acute gastric volvulus is often definitively diagnosed only during surgical exploration.

Chronic gastric volvulus is usually partial and non-obstructive, and may present with no obvious symptoms or only mild symptoms resembling chronic conditions such as ulcer disease or chronic cholecystitis. Barium meal examination is an important diagnostic method. For mesenteroaxial volvulus, the X-ray findings include a double-peaked gastric cavity with two fluid levels, and the pylorus and cardia lying at similar levels. For organoaxial volvulus, the X-ray findings include inversion of the greater and lesser curvatures of the stomach and a gastric fundus fluid level that does not connect with the gastric body.

Acute gastric volvulus must be treated surgically; otherwise, the blood circulation of the gastric wall may be compromised, leading to necrosis. If a gastric tube can be successfully inserted to aspirate gas and fluid from the stomach, surgical treatment may be considered after acute symptoms are alleviated and further examinations are conducted. When the abdominal cavity is opened, the first thing usually seen is the tense posterior gastric wall behind the transverse mesocolon. Due to the disorganized anatomical relationships and the distended gastric wall, surgeons often find it difficult to clearly identify the pathological condition. At this point, it is advisable to aspirate the accumulated gas and fluid in the stomach through a gastric wall puncture, suture the puncture site, and then proceed with exploration. After the gastric body is repositioned, the discovered pathological changes—such as diaphragmatic hernia, hiatal hernia, tumors, or adhesive bands—should be treated with resection or repair. If no relevant {|###|}disease cause{|###|} or pathological mechanism can be identified, a gastropexy may be performed. This involves densely suturing the gastrocolic ligament and gastrosplenic ligament from the splenic {|###|}root of nose{|###|} to the gastric cardia onto the anterior abdominal wall peritoneum to prevent recurrence of the volvulus.

Partial gastric volvulus accompanied by conditions such as {|###|}ulcer{|###|} or {|###|}bottle gourd peel{|###|} stomach may be treated with partial gastrectomy, and addressing the {|###|}disease cause{|###|} is crucial.

Preoperative attention should be paid to correcting water and electrolyte imbalances. Postoperatively, gastrointestinal decompression should be continued for several days.