Editing Gastric volvulus

The stomach or part of the stomach is rotated at least 180 degrees along its longitudinal or transverse axis


== '''Classification''' ==

* '''Anatomical''' (not clinically as important)
** Organoaxial (35%)
*** Stomach rotates around its       longitudinal axis (a transverse line between the pylorus and GOJ)
*** In most cases the antrum       rotates anteriorly and superiorly and the fundus posteriorly and       inferiorly, and the greater curvature comes to lie superior to the       lesser curvature
** Mesenteroaxial (65%)
*** Stomach rotates around its       short axis - a longitudinal line parallel to the gastrohepatic omentum,       connecting the middle of the greater and lesser curvatures
*** Pylorus rotates anteriorly       and superiorly (most common), but can sometimes move posteriorly from       right to left
*** The posterior of the       stomach lies anteriorly
** Combined (2%)
* '''Aetiological'''
** Primary (30%):
*** Rotation due to       laxity/disruption of the gastric ligaments. Due to agenesis, elongation,       or disruption (neoplasia, adhesions, skeletal deformity). More common       with chronic symptoms.
*** Usually mesenteroaxial
** Secondary (70%):
*** Volvulus due to other       anatomical abnormalities (paraoesophageal hernia (most common),       congenital diaphragmatic hernia, diaphragmatic eventration, phrenic       nerve paralysis)
*** Mostly organoaxial
* '''Onset'''
** Acute
** Chronic

== '''Pathophysiology''' ==

* Stomach rotation >180     degrees causes complete gastric outlet obstruction, and partial is less     likely with smaller rotations
* Strangulation is much more     common with organoaxial than mestenteroaxial, and can occur with torsion     >180 degrees

== '''Risk factors''' ==

* Age >50 years
* Diaphragmatic abnormalities
* Phrenic nerve paralysis
* Kyphoscoliosis

== '''Presentation:''' ==

* Borchardt's Triad - sudden     onset of constant and severe epigastric pain, retching with minimal     vomitus, and inability to pass NGT (70% have it)
* Haematemesis can occur
* Gastric outlet obstruction
* Suspect strangulation with     fever, tachycardia and leukocystosis
* Chronic/subacute symptoms are     often vague and non-specific

== '''Investigation:''' ==

* CXR - single large, '''spherical''' gas bubble in upper abdomen     or chest with air-fluid level. Note that other aetiologies of GOO are less     likely to have a spherical contour
**
* CT - dilated stomach, often     abnormal position, swirl sign (oesophagus and stomach rotating around one     another), look for gastric necrosis
* Gastroscopy: tortuous     stomach, paraoesophageal hernia, inability to locate and pass through the     pylorus, possibly evidence of gastric ischaemia

== '''Initial management:''' ==

* NGT (if bedside NGT is not     possible, can do gastroscopy-assisted and decompress the stomach at the     same time)
** Can sometimes detort the      stomach spontaneously
* Resuscitate
* Antibiotics
* Many would argue for routine     gastroscopy, even if NGT is in

== '''Immediate surgery if:''' ==

* Inability to decompress     stomach with NGT +/- endoscopy
* Gastric ischaemia seen on     endoscopy
* Gastric perforation or     mediastinal contamination
* Shock/hypotension refractory
* Severe sepsis

== '''Definitive treatment''' ==

* Goals - return stomach to     anatomic position, repair associated abnormalities, and prevent recurrence     (otherwise occurs in 64% of patients treated conservatively)
* In unstable patients, open     approach is recommended
* OT can be done electively in     patients that improve well or achieve detorsion with low risk of     strangulation
* '''Technique'''
** Abdominal approach with      upper midline laparotomy (can sometimes be done laparoscopically)
** Decompression, detorsion,      and observation for ischaemia
*** Any strangulated segments       need to be resected
**** Close the stomach if you        can
**** If patient is unstable and        large gastric resection is required, drain the distal oesophagus, close        the duodenal stump and place a feeding jejunostomy. Roux-en-Y        jejuno-oesophagostomy will subsequently be needed.
*** If unable to reduce:
**** Guide NGT into place
**** Consider aspirating        contents of stomach via needle or gastrotomy
**** Thoracotomy
** If the '''patient is      stable''', fix any      diaphragmatic defect and do a proper 'elective' repair
*** Excise hernia sac
*** Suture the crura
*** If a paraoesophageal hernia       was present, consider a fundoplication
** If the '''patient is      unstable''', just      do a suture gastropexy to anterior abdominal wall and complete the      operation
* Stable patients with high     surgical risk could have PEG gastropexy (two tube gastrostomies will fix     the stomach better than one) but this is uncommonly done
** This could also be done for      a spontaneous volvulus


[[Category:UGIS]]