Gastric volvulus

Background

• Abnormal rotation of the stomach around its short or long axis
• Rare but potentially life-threatening due to potential for untreated volvulus to progress to strangulation and cause gastric ischemia and perforation
• Usually associated with paraesophageal hernia or diaphragmatic eventration

Clinical Features

• Usually appear relatively well until progressed to gastric ischemia
• Abdominal pain/tenderness and distension, particularly upper abdomen
• Vomiting, retching that often does not respond to antiemetics

Differential Diagnosis

Diffuse Abdominal pain

• Abdominal aortic aneurysm
  • Aortocaval fistula
• Acute gastroenteritis
• Aortoenteric fisulta
• Appendicitis (early)
• Bowel obstruction
  • Large bowel obstruction
    • Ogilvie's syndrome
  • Small bowel obstruction
  • Malignant bowel obstruction
• Bowel perforation
• Diabetic ketoacidosis
• Gastroparesis
• Hernia
• Hypercalcemia
• Inflammatory bowel disease
• Mesenteric ischemia
  • Mesenteric vein thrombosis
• Pancreatitis
• Peritonitis
• Sickle cell crisis
• Spontaneous bacterial peritonitis
• Volvulus

Epigastric Pain

• Gastroesophageal reflux disease (GERD)
• Peptic ulcer disease with or without perforation
  • Zollinger-Ellison syndrome
• Gastritis
• Pancreatitis
• Gallbladder disease
  • Acute cholecystitis
  • Cholangitis
  • Symptomatic cholelithiasis
  • Acalculous cholecystitis
• Myocardial Ischemia
• Splenic Infarctionenlargement/rupture/aneurysm
• Pericarditis/Myocarditis
• Aortic dissection
• Hepatitis
• Pyelonephritis
• Pneumonia
• Pyogenic liver abscess
• Fitz-Hugh-Curtis Syndrome
• Hepatomegaly due to CHF
• Bowel obstruction
• SMA syndrome
• Pulmonary embolism
• Bezoar
• Ingested foreign body

Evaluation

• Evaluate for other causes of pain
• CXR may show retrocardiac air-filled gastric shadow
• Upright CXR and abdominal x-ray
  • Intrathoracic, upside-down stomach
  • Double air fluid level in stomach
  • Collapsed small bowel
• CT abdomen most helpful
  • Gastric herniation around points of torsion
  • May show signs of gastric ischemia, seen a lack of contrast enhancement of gastric wall

Management

• NG tube for decompression
• Surgery consult
• Analgesia

Disposition

• Admit