Gastric volvulus in adults

INTRODUCTION — Gastric volvulus is characterized by rotation of the stomach along its long or short axis leading to variable degrees of gastric outlet obstruction, which may present acutely or chronically. Rotation of the stomach more than 180° causes complete gastric outlet obstruction; potentially, ischemia or strangulation of the stomach; and, potentially, necrosis, perforation, and abdominal sepsis. Mortality related to acute gastric volvulus is high if unrecognized, underscoring the need for early diagnosis and treatment [1-4].

The classification, clinical manifestations, diagnosis, and treatment of gastric volvulus will be reviewed here. General considerations for gastric outlet obstruction are discussed elsewhere. (See "Gastric outlet obstruction in adults".)

EPIDEMIOLOGY AND RISK FACTORS — Gastric volvulus is rare. The incidence peaks after the fifth decade, with adults constituting 80 to 90 percent of cases [5]. No association with sex or race has been reported.

Risk factors — Risk factors for gastric volvulus in adults include the following [1]:

●Age >50 years

●Diaphragmatic abnormalities (eg, paraesophageal hernia, hiatal hernia, other diaphragmatic hernia)

●Diaphragmatic eventration

●Phrenic nerve paralysis

●Other anatomic gastrointestinal (eg, stomach) or splenic abnormalities

●Kyphoscoliosis

PATHOGENESIS — Gastric volvulus is characterized by abnormal rotation of the stomach along its horizontal or vertical axis. The stomach is normally maintained in position by several ligaments that fix the stomach to other abdominal structures and to the diaphragm, including the gastrocolic, gastrohepatic, gastrosplenic, and gastrophrenic ligaments (figure 1) [1]. Together with the gastroesophageal junction and pylorus, these ligaments anchor the stomach and prevent rotation.

Gastric outlet obstruction occurs to a varying degree depending upon the amount of rotation. With stomach rotation >180°, complete gastric outlet obstruction occurs, but with lesser degrees of rotation, the gastric obstruction is partial [6].

Chronic rotation of the stomach can cause decreased venous return and increased capillary pressure that can lead to gastric bleeding.

CLASSIFICATION — Gastric volvulus is classified as primary (idiopathic) or secondary depending upon its etiology, organoaxial or mesenteroaxial according to axis of rotation, and acute or chronic depending upon the clinical presentation.

Primary versus secondary gastric volvulus — Primary (idiopathic) gastric volvulus is defined as volvulus due to abnormalities of the gastric ligaments [7]. Failure of the gastric fixation can occur as a result of agenesis, elongation, or disruption of the gastric ligaments due to neoplasia, adhesions, or skeletal deformity [1]. As an example, kyphoscoliosis can lead to primary gastric volvulus due to displacement of the viscera producing abnormal tension and therefore elongation of the ligaments over time [8]. Primary gastric volvulus presents more commonly with chronic symptoms.

Secondary gastric volvulus occurs in two-thirds of patients with gastric volvulus and is defined as volvulus due to other anatomic abnormalities (ie, not primarily the gastric attachments), such as paraesophageal hernia, diaphragmatic hernia (Morgagni hernia, Bochdalek hernia, traumatic hernia), diaphragmatic eventration, or phrenic nerve paralysis, as well as anatomic abnormalities of other organs (eg, stomach, spleen) [1,3,4,6,9-13].

In adults, the most commonly associated diaphragmatic defect is paraesophageal hernia [1,6,11]. Patients who have had weight loss surgeries, such as adjustable gastric banding or sleeve gastrectomy, have also been reported to present with gastric volvulus as a complication [14,15].

By contrast, in children, congenital diaphragmatic hernia is the most commonly associated anatomic abnormality [11,12,16,17]. "Wandering spleen" (a mobile spleen only attached by an elongated vascular pedicle) and gastric volvulus have been described in association with congenital diaphragmatic hernia, both conditions resulting from abnormal laxity or absence of peritoneal attachment due to congenital abnormalities [18,19].

Organoaxial versus mesenteroaxial volvulus — Gastric volvulus can also be classified based upon the axis of abnormal rotation (long versus short axis).

●Organoaxial rotation refers to rotation of the stomach along its long axis through a line that connects the gastroesophageal junction and the pylorus (figure 2). The antrum rotates anterosuperiorly and the fundus rotates posteroinferiorly. The greater curvature of the stomach comes to rest superior to the lesser curvature of the stomach in an inverted position (upside-down stomach) [1]. Organoaxial volvulus is the most common type of abnormal rotation, occurring in 60 percent of cases of gastric volvulus, and is associated with secondary etiologies (eg, paraesophageal hernias, diaphragmatic hernia, and diaphragmatic eventration) [7,10]. Strangulation of the stomach is more common with this type of volvulus, occurring in up to 30 percent of cases [1,7]. (See 'Primary versus secondary gastric volvulus' above.)

●With mesenteroaxial volvulus, the stomach rotates around its short axis through a perpendicular line connecting the greater and lesser curvatures of the stomach (figure 2). The antrum becomes displaced above the gastroesophageal junction [1]. With mesenteroaxial volvulus, rotation is usually partial (<180°) and is not generally associated with a secondary anatomic defect. (See 'Primary versus secondary gastric volvulus' above.)

●A complex form of gastric volvulus combines elements of organoaxial and mesenteroaxial rotation (figure 2).

Acute versus chronic gastric volvulus — The clinical manifestations associated with gastric volvulus vary depending upon the degree of gastric outlet obstruction and rapidity of onset. With rotation >180°, the patient will present with symptoms of acute gastric outlet obstruction (ie, acute gastric volvulus), whereas in those with lesser degrees of rotation, symptoms of partial gastric obstruction occur that can be intermittent and chronic [6]. Approximately 40 percent of patients with gastric volvulus present with an acute onset of symptoms [1]. Patients with chronic gastric volvulus can also present with acute symptoms superimposed on their chronic picture.

CLINICAL PRESENTATIONS — Most patients with gastric volvulus come to medical attention because of symptoms, which can present acutely or chronically, most commonly with abdominal or chest pain. It is a rare condition, so it is often not initially considered as the underlying cause of these symptoms. The general approach to the patient with abdominal or chest pain is discussed elsewhere. Clinical features related to gastric volvulus are presented below. (See "Evaluation of the adult with abdominal pain" and "Outpatient evaluation of the adult with chest pain".)

A history of risk factors associated with gastric volvulus as well as any prior injuries, surgeries, and known anatomic abnormalities should be sought. A history of other upper gastrointestinal diseases, such as a history of gastroesophageal reflux, may indicate the presence of a paraesophageal hernia and suggest the diagnosis, whereas a history of peptic ulcer disease may point to an alternative etiology for gastric outlet obstruction. (See 'Risk factors' above and 'Differential diagnosis' below.)

Acute gastric volvulus — Acute symptoms include pain in the upper abdomen or lower chest associated with severe vomiting (which may become unproductive). The combination of pain, vomiting, and an inability to pass a nasogastric tube, known as Borchardt's triad, is present in as many as 70 percent of patients with acute gastric volvulus [2,20]. Hematemesis can occur due to mucosal ischemia or mucosal tears from vomiting [1,10,21]. Also reported are pain related to pancreatic or omental ischemia, omental avulsion, or splenic rupture due to traction on these structures [1,6,17,21,22].

With complete gastric outlet obstruction, the stomach becomes dilated and fluid filled, manifesting as upper abdominal distention with dullness to percussion [3,10]. The physical examination may also reveal evidence of volume depletion. Auscultation may reveal gastric sounds in the chest. Signs of peritonitis (abdominal wall rigidity, rebound tenderness) may be present if significant gastric ischemia due to strangulation or perforation has occurred. The acute presentation of gastric volvulus can be confused with acute coronary syndrome, which can delay the diagnosis [23,24].

Most patients undergo initial laboratory testing for the evaluation of acute abdominal or chest pain that includes a complete blood count, electrolytes, and possibly liver function tests and pancreatic enzymes. These studies may help identify patients who are volume depleted or experiencing complications but do not help establish a diagnosis of gastric volvulus. (See 'Diagnostic evaluation' below.)

Patients with recurrent vomiting may have electrolyte abnormalities, including hypokalemia or a hypochloremic metabolic alkalosis, or evidence of volume depletion. (See "Causes of metabolic alkalosis".)

Laboratory findings may also include an elevated white blood cell count, which may be due to inflammation, and acute stress and pain related to acute gastric distention. However, if the white blood cell count remains elevated following decompression of the stomach and measures to control pain, it may relate to ischemia, gastric perforation, and abdominal sepsis requiring urgent endoscopic evaluation or abdominal exploration. (See 'Subsequent care' below.)

Other nonspecific laboratory findings may include elevated pancreatic enzymes and anemia related to mucosal ulceration [1].

Chronic gastric volvulus — Patients with chronic or intermittent gastric volvulus have vague and often subclinical presentations.

Chronic symptoms include mild upper abdominal discomfort, distension or bloating, retching or nonbilious vomiting, dysphagia, early satiety, and heartburn, and occasionally patients present with symptoms of pancreatitis [25]. Chronic rotation of the stomach can lead to gastric ulceration, low-level bleeding, and chronic anemia. Some patients with chronic gastric volvulus will have a history of multiple transfusions.

The physical examination in patients with chronic gastric volvulus may be relatively nonspecific. Since the stomach is often located in the chest, there can be minimal abdominal distention. Patients may also lack abdominal tenderness.

In patients with chronic gastric volvulus, laboratory studies obtained in the course of evaluating the patient with chronic abdominal or chest complaints may show chronic anemia from gastric ulceration due to the abnormal stomach rotation. Pancreatic enzymes may also be elevated [1].

DIAGNOSTIC EVALUATION — A diagnosis of gastric volvulus cannot be made with history and physical examination alone. Because it is a rare condition, it is usually not the foremost diagnosis expected as the cause of upper abdominal pain, nausea, and vomiting. The radiologic evaluation of abdominal or chest pain typically involves plain radiographs or computed tomography (CT).

Acute symptoms — For patients suspected of acute gastric volvulus based upon clinical features, we suggest plain radiography as the initial diagnostic test. Classic findings may confirm the diagnosis, indicating immediate nasogastric decompression without further delay. (See 'Gastric decompression' below.)

The classic finding of acute gastric volvulus on plain abdominal radiograph is a single large, spherical gas bubble located in the upper abdomen or chest with an air-fluid level (image 1) [26]. There is generally a paucity of air in the distal bowel [22]. With other etiologies of gastric outlet obstruction, the stomach retains a more normal contour (ie, not spherical) (image 2).

A distinguishing feature of organoaxial volvulus is that the stomach lies in a horizontal plane when viewed on plain radiographs (image 3A) [6,10,11]. Mesenteroaxial volvulus will have a spherical stomach on supine images but two air-fluid levels on upright films, with the antrum positioned superior to the fundus (image 3B) [4,27]. Prior placement of a nasogastric tube may dissipate the gastric bubble, but the course of the nasogastric tube will remain abnormal.

If the classic features are not present on plain radiography but acute gastric volvulus is suspected, we suggest CT rather than gastrointestinal contrast studies. Both will show the abnormal position of the stomach, but CT has the added advantage of showing the relationship of the stomach to surrounding structures and identifying anatomic abnormalities associated with secondary gastric volvulus. In a study of 36 patients with acute gastric volvulus, barium swallow was diagnostic in only two of four patients, whereas CT diagnosed all 26 [28]. (See 'Primary versus secondary gastric volvulus' above.)

CT of the abdomen or chest typically demonstrates a dilated stomach, often abnormally positioned in the chest (image 4). A swirl sign, in which the esophagus and stomach rotate around each other on transverse plane images, may also be evident [26,29]. Findings suggestive of gastric necrosis include pneumatosis of the gastric wall, free air and fluid outside the gastric wall within the hernia sac, and lack of contrast enhancement of the gastric wall [28]. CT also defines other anatomic abnormalities, such as diaphragmatic defects, and excludes other abdominal pathology as the source of symptoms [2,6,10,17,26].

Chronic symptoms — A diagnosis of chronic gastric volvulus relies on demonstrating abnormal positioning of the stomach on imaging studies (plain film, CT), which are typically obtained as part of the evaluation of chronic abdominal or chest complaints. The classic features of gastric volvulus typical for acute gastric volvulus on plain chest and abdominal films are frequently absent in patients with incomplete or partial volvulus (rotation <180°). (See 'Acute symptoms' above.)

Plain radiographs may demonstrate abnormal positioning of the stomach, but the findings may be subtle. If a degree of obstruction is present, the stomach bubble is less dramatic and air will be present in the distal bowel. These patients may exhibit no evidence of obstruction at imaging [22]. If plain films are unrevealing, CT of the abdomen may show the abnormal position of the stomach and has the advantage of showing the relationship of the stomach to surrounding structures.

If the diagnosis remains in question, upper gastrointestinal (UGI) series are another imaging option and are sensitive and specific when performed with the stomach in the "twisted" state [4,7,22,29]. The greater curve will be inverted above the lesser curve (organoaxial volvulus), or the pylorus will be seen above the gastric fundus (mesenteroaxial volvulus) (image 3A-B). A disadvantage of UGI series is that they do not identify other anatomic abnormalities that might be associated with secondary volvulus.

Patients with chronic upper abdominal symptoms often undergo upper endoscopy as part of their evaluation. Although endoscopic diagnosis of gastric volvulus has a low sensitivity of 32 to 45 percent [25,28], endoscopy may be helpful for ruling out other upper gastrointestinal diseases in the differential diagnosis, aiding placement of a nasogastric tube, or providing stomach fixation using a percutaneous gastrostomy (PEG) tube. (See 'Differential diagnosis' below and 'Poor surgical candidates' below.)

DIFFERENTIAL DIAGNOSIS — Other conditions can cause acute abdominal pain and gastric outlet obstruction manifesting with acute gastric distention on imaging studies. (See "Gastric outlet obstruction in adults", section on 'Etiology'.)

Acute gastric dilation can also occur in the absence of mechanical obstruction related to psychological disorders [30]. However, with acute gastric volvulus, the stomach contour assumes a more spherical contour (image 1) due to the abnormal rotation. When the stomach is not twisted, the stomach is distended but maintains a relatively normal stomach contour (image 2).

The past medical history may suggest an alternative cause for nausea, vomiting, and abdominal pain, and, for many causes of gastric outlet obstruction, the pathology will be apparent on imaging studies (eg, mass, inflammation). (See "Gastric outlet obstruction in adults", section on 'Etiology'.)

The diagnosis and differential diagnosis of abdominal pain and the many causes of gastric outlet obstruction are discussed in more detail elsewhere. (See "Causes of abdominal pain in adults" and "Gastroparesis: Etiology, clinical manifestations, and diagnosis".)

INITIAL TREATMENT — Most patients diagnosed with gastric volvulus come to medical attention because of acute symptoms. Initial treatment involves stabilizing the patient (fluid resuscitation and correction of electrolyte abnormalities) and immediate gastric decompression (algorithm 1).

If the diagnosis is made at a clinician's office or in the emergency department, admission to the hospital should be arranged. Direct admission to a surgical service or surgical consultation is appropriate for any symptomatic patient with gastric volvulus [11,17].

Resuscitation — Intravenous lines should be placed and fluid and electrolyte therapy administered as needed. Broad-spectrum antibiotics should be administered early to those with suspected gastric ischemia or perforation or mediastinitis [28,31].

Gastric decompression — Gastric decompression reduces tension in the stomach wall and improves perfusion, decreasing the risk for gastric ischemia and necrosis. (See "Gastric outlet obstruction in adults", section on 'Management'.)

●Nasogastric tube decompression – For patients with acute symptoms and severe gastric distention on imaging or imaging features that suggest gastric volvulus, we suggest that a nasogastric tube be immediately placed by someone with experience and knowledge of the underlying pathology [1,2,28]. (See "Gastric outlet obstruction in adults", section on 'Management' and "Inpatient placement and management of nasogastric and nasoenteric tubes in adults", section on 'Tube placement'.)

●Endoscopic-assisted decompression – Endoscopy can be used to assist placement of a nasogastric tube if a bedside attempt has failed. Endoscopic decompression can be accomplished by directing the endoscope under vision into the stomach. While guiding the scope, minimal or no insufflation should be used. Once the scope is in the distal stomach, the accumulated air and gastric contents are suctioned to the extent that is possible and the gastric mucosa assessed for viability. A nasogastric tube can then be placed either blindly following the endoscope or under direct vision. (See "Overview of upper gastrointestinal endoscopy (esophagogastroduodenoscopy)".)

In patients with acute gastric volvulus, endoscopic decompression and/or derotation are best performed with a controlled airway (ie, patient anesthetized and intubated) in an operating room or appropriately equipped endoscopy suite with anesthesia availability. That is because the patient's cooperation with bedside nasogastric tube placement is often limited by discomfort related to the volvulus, and pulmonary aspiration of gastric contents can occur.

●Surgical intervention is required if gastric decompression is unsuccessful via nasogastric tube or endoscopic techniques. (See 'Immediate surgery' below.)

Subsequent care — With successful passage of the nasogastric tube into the distal stomach, there is usually immediate resolution of gastric distension and abdominal pain; however, the stomach may or may not derotate spontaneously. Although distal gastric obstruction from stomach rotation may still exist, the risk of gastric necrosis is reduced.

A repeat abdominal film should be performed to confirm the position of the tube, effectiveness in decompressing the stomach, and course of the tube. The nasogastric tube should remain in place to keep the stomach decompressed until definitive repair. During the period of time prior to definitive repair, the patient should remain pain free and hemodynamically stable and have no systemic signs that might indicate tissue ischemia or abdominal sepsis (eg, fever, increasing white blood cell count). As long as the patient is stabilized with the help of nasogastric tube decompression, definitive treatment can be delayed but should occur during the index hospitalization. This delay permits the patient to be assessed for anesthesia risk or transferred to a higher-acuity facility if necessary. (See 'Definitive treatment' below.)

However, the following situations mandate immediate surgery. Such patients likely have gastric ischemia, necrosis, and/or perforation, which can only be salvaged by surgical source control [28,32] (see 'Immediate surgery' below):

●Inability to decompress the stomach with a nasogastric tube or endoscopic-assisted techniques (ie, strangulation).

●Gastric perforation or mediastinal contamination confirmed by imaging (usually computed tomography [CT]). (See 'Acute symptoms' above.)

●Shock or hypotension refractory to resuscitation.

●Severe sepsis.

Stable patients with one of the following characteristics may benefit from endoscopic evaluation. Endoscopic evidence of gastric ischemia or necrosis will mandate immediate surgery, whereas absence of gastric ischemia may allow patients to wait for a few more days before urgent surgical repair to allow dissipation of gastric edema.

●Persistent or recurrent chest or abdominal pain following adequate gastric decompression without CT evidence of complication (eg, perforation).

●Mild sepsis (eg, persistently elevated white blood cell count) without CT evidence of complication.

DEFINITIVE TREATMENT — Gastric volvulus is a rare condition, but case series and retrospective reviews show better outcomes for patients who undergo some form of definitive treatment [1,3,5,7]. Without such treatment, volvulus can recur, leading to the return of symptoms and potentially complications. (See 'Recurrence' below.)

The definitive treatment should be tailored to the patient's clinical status (stable versus unstable), the etiology of the gastric volvulus (primary or secondary) as determined by history and imaging, the chronicity of the symptoms (acute versus chronic), and the patient's surgical anesthetic risk (good versus poor surgical candidate) (algorithm 1).

Immediate surgery — Immediate or urgent surgery for gastric volvulus is only indicated when the stomach cannot be decompressed with a nasogastric tube at the bedside and with endoscopic assistance or when there is a complication (eg, gastric perforation or necrosis) based on clinical, radiologic, or endoscopic assessment. (See 'Subsequent care' above.)

●For unstable patients, most authors suggest an open approach. Once the gastric volvulus is reduced, the stomach should be examined for areas of ischemia. Decompression and derotation of the stomach results in rapid reperfusion. If ischemic areas are observed, the tissue should be observed intraoperatively for 10 to 15 minutes after derotation. If color and pliability do not improve, resection should be performed or a second-look operation planned. The majority of gastric necrosis and/or perforation occurs at the fundus, a location amenable to sleeve resection with a linear stapler [28].

Partial gastrectomy or, rarely, subtotal gastrectomy may be needed; however, because of the robust circulation to the stomach, this is uncommon. If the entire stomach is necrosed and not viable, the recommendation is for a total gastrectomy without reconstruction with a jejunostomy tube and an esophagostomy. Patients are generally too ill to undergo a reconstruction at this time. Once patients are stable and recovered, one can return electively for an esophagojejunal reconstruction or colon interposition. (See "Partial gastrectomy and gastrointestinal reconstruction" and "Total gastrectomy and gastrointestinal reconstruction".)

Unstable patients with metabolic derangements might benefit from damage control laparotomy for rapid reduction and resection of necrotic tissue, followed by a planned second look after further resuscitation for definitive repair [31]. (See "Overview of damage control surgery and resuscitation in patients sustaining severe injury", section on 'Damage control laparotomy'.)

●Stable patients may undergo either open or laparoscopic surgery. Following reduction and detorsion of the stomach, either surgical repair of the anatomical defect (for secondary volvulus) or gastropexy (for primary volvulus) [33] can be performed. Gastropexy without correction of the anatomical defect is a reasonable option for secondary gastric volvulus in patients who cannot tolerate a prolonged operation due to comorbidities. (See 'Delayed definitive treatment' below.)

Delayed definitive treatment — Clinically stable patients with acute presentation, but whose symptoms improve with resuscitation and gastric decompression (most patients), and patients with chronic presentation can avoid immediate surgery but undergo planned definitive treatment after completing diagnostic evaluation and medical/anesthetic risk assessment [32].

The goals of treating patients with gastric volvulus are restoring the stomach back to a more normal anatomic position, repairing any associated anatomic abnormalities, and preventing future stomach rotation [1,3,17,34,35]. These goals can be accomplished with endoscopic or surgical (open or laparoscopic) techniques. However, endoscopic management does not address anatomic abnormalities and thus may be less optimal for patients with secondary volvulus.

Primary gastric volvulus — For patients with primary chronic gastric volvulus, gastric fixation after successful derotation, which involves tethering the anterior wall of the stomach to the posterior aspect of the abdominal wall, may be adequate for preventing recurrent rotation.

Gastric fixation can be accomplished endoscopically using percutaneous endoscopic gastrostomy (PEG) tubes, surgically by directly suturing the stomach to the abdominal wall (open or laparoscopic gastropexy), or by a combination of the two methods (eg, laparoscopic gastropexy with PEG tube placement). The approach depends on patient condition and clinician preference.

●Surgical gastropexy – The technique of suture gastropexy has not been standardized. Most published techniques describe one- or two-point gastric fixation using a combination of sutures and PEG tubes [36-39]. Concerned about recurrent volvulus, one author described a technique of suturing the stomach to the diaphragm and anterior abdominal wall using 2-0 silk sutures every 3 cm along the greater curvature [33].

●Endoscopic gastropexy – Gastric fixation using PEG can be performed after endoscopic or surgical detorsion (see 'Poor surgical candidates' below). Whereas PEG tubes provide the gastric fixation with endoscopic treatment, it is not known whether they are required to augment gastropexy sutures after surgical detorsion. In one report of surgical gastropexy, PEG actually caused several of the serious complications, which prompted the authors to suggest PEG tube placement only in patients who require the tube for feeding postoperatively [33].

Secondary gastric volvulus — For symptomatic patients with secondary gastric volvulus, we suggest surgical repair of the anatomic defect (most commonly paraesophageal hernia in adults) rather than gastric fixation alone (algorithm 1). Surgical repair appears to reduce the risk of future recurrence. For patients with significant medical comorbidities, not repairing the anatomic defect is an acceptable alternative, provided that gastric derotation and fixation have been accomplished (laparoscopic or endoscopic). (See 'Poor surgical candidates' below.)

For patients with moderate-to-severe symptoms from chronic secondary gastric volvulus, we also suggest surgical repair rather than observation. For those with minimal symptoms, conservative management without intervention may be more appropriate, particularly if the patient has limited life expectancy or is a poor candidate for repair [25,40-42]. (See "Surgical management of paraesophageal hernia", section on 'Indications for surgical repair'.)

Surgical repair for secondary gastric volvulus consists of derotating the stomach, removing any nonviable tissue, reducing any hernias, and repairing anatomic defects [1,3,17,34,35,43].

●Reduction and derotation of the stomach – Reduction of the stomach from the hernia sac is started anteriorly with gentle downward traction on the hernia sac (movie 1). Sac reduction will bring down most stomachs without having to touch the stomach. To avoid injury, the stomach should be directly retracted only when absolutely necessary, and with atraumatic graspers. There are often adhesions of the stomach or omentum that will not be appreciated until the stomach is nearly reduced. With methodical dissection, the stomach will eventually be delivered into the abdomen, where it can be manually derotated.

●Gastrectomy – Once reduced, the stomach should be examined for areas of ischemia (movie 2). Ischemic, necrotic, or perforated gastric tissue should be resected. (See 'Immediate surgery' above.)

●Repair of anatomic defects – When gastric volvulus is found to be due to a diaphragmatic defect (usually paraesophageal hernia), repair of the defect reduces the risk of recurrent volvulus. Once the stomach has been reduced and derotated, the hernia sac is resected (movie 3). The distal esophagus is mobilized, and an antireflux procedure and closure of the hiatus with or without mesh are performed. The surgical techniques related to paraesophageal hernia are discussed elsewhere. (See "Surgical management of paraesophageal hernia".)

●Gastric fixation – Gastric fixation is not required or routinely performed following repair of an anatomic defect (eg, paraesophageal hernia). It is, however, an essential step in the repair of primary gastric volvulus and may be performed in lieu of definitive anatomical repair in secondary volvulus patients who cannot withstand prolonged anesthesia or pneumoperitoneum [33]. (See 'Primary gastric volvulus' above and 'Immediate surgery' above.)

The surgical management of gastric volvulus was traditionally performed as an open procedure [1], but laparoscopic repair is feasible for patients who present both acutely and chronically [44]. Although there have been no randomized trials directly comparing long-term outcomes, observational studies [29,34,38,45-48], as well as indirect evidence from the approach to the repair of paraesophageal hernia and other diaphragmatic hernias, suggest that a laparoscopic approach may be preferred to open surgery because it is less invasive; offers greater visualization, particularly into the mediastinum; and has the advantages of a shorter hospital stay and reduced perioperative morbidity [4,29,33,45-47,49]. Since gastric volvulus is more often associated with paraesophageal hernias in older adult patients, a laparoscopic approach may be desirable, particularly in those with medical comorbidities [4]. The decision rests largely upon the experience and preference of the surgeon and the available resources.

Poor surgical candidates — A less invasive approach can be used in patients who have medical comorbidities that preclude surgery (algorithm 1). This approach consists of endoscopic derotation and gastric fixation, without repair of the anatomic defect [2,4,10,16,34]. If endoscopic derotation is successful, PEG tubes are placed [36,37,49-51].

Endoscopic derotation and PEG tube placement are often used as a first-line therapy to manage patients with primary gastric volvulus and in those patients with secondary gastric volvulus who are poor candidates for surgical repair (algorithm 1). However, endoscopic derotation maneuvers may not be successful, and a surgical approach may, nevertheless, be needed.

If the stomach remains rotated on repeat radiography following nasogastric tube placement (bedside or endoscopic assisted), endoscopic derotation can be attempted [50,51]. The endoscope is guided through the stomach beyond the twist and manipulated within the stomach [52,53]. If the stomach derotates, the endoscope should be guided into the duodenum, ensuring the stomach is fully derotated. If the stomach is unable to be reduced endoscopically, then operative decompression and derotation will be needed. (See 'Immediate surgery' above.)

If the stomach returns to a normal position, PEG tubes can be placed to fix the stomach into position. From a practical standpoint, we place at least two PEG tubes to prevent future rotation (organoaxial or mesenteroaxial) when fixating the stomach. One of the PEG tubes is placed into the gastric body, and another is placed more distal in the stomach. With only a single PEG tube, the stomach can still rotate around the axis from the PEG tube to the gastroesophageal junction.

After PEG tubes are placed, they are placed to gravity drainage for 12 to 24 hours, after which time they are capped and only opened for signs and symptoms of gastric distension [33]. Most PEG tubes are never used for feeding but are left in place for 6 to 12 weeks to allow adhesions to form between the stomach and abdominal wall. Thereafter, the tubes are discontinued.

The fixation bars need to be loosened in a few days, as PEG tubes are prone to erosion and leak in this patient population that is too morbid to tolerate surgery. Given the advances and benefits of minimally invasive surgery, however, most patients should be able to tolerate a laparoscopic procedure for more definitive management [33,44].

RECURRENCE — Recurrence of unrepaired gastric volvulus is common. In a study of patients with chronic volvulus, recurrent symptoms in 44 conservatively managed patients occurred in 64 percent of patients but did not lead to any serious complications [25].

There are very few data with regard to recurrence of gastric volvulus following repair. In theory, surgically corrected gastric volvulus should not recur, and if it does, it indicates failure of the anatomic repair or inadequate fixation of the stomach to the abdominal wall. In a study comparing recurrence rates associated with gastric fixation alone, recurrence occurred in 42 percent of patients using a laparoscopic approach versus 15 percent with the open approach [54]. In the paraesophageal hernia repair literature, a recurrence rate of 8 percent is reported; however, this does not reflect recurrence related to gastric volvulus but rather the recurrence of a hernia. (See "Surgical management of paraesophageal hernia", section on 'Patient outcomes'.)

Despite the risk of recurrence, surgical repair has been associated with significant improvement in quality of life for patients, with studies demonstrating improved social function and physical quality-of-life scores. The risk for general symptom recurrence is low [44,55].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Bowel obstruction".)

SUMMARY AND RECOMMENDATIONS

●Gastric volvulus is a rare condition that can be life-threatening. Gastric volvulus is characterized by abnormal rotation of the stomach along its long or short axis, which leads to varying degrees of gastric outlet obstruction. If rotation is more than 180°, gastric outlet obstruction is complete. (See 'Introduction' above and 'Epidemiology and risk factors' above.)

●Primary (idiopathic) gastric volvulus is defined as volvulus due to abnormalities of the gastric ligaments. Secondary gastric volvulus occurs in two-thirds of patients with gastric volvulus and is defined as volvulus due to other anatomic abnormalities, the most common of which is paraesophageal hernia in adults and congenital diaphragmatic hernia in children. (See 'Primary versus secondary gastric volvulus' above.)

●Stomach rotation is described as organoaxial, twisting along the stomach's long axis from the pylorus to esophagogastric junction, or mesenteroaxial, twisting along its short axis. Organoaxial volvulus is more common. (See 'Organoaxial versus mesenteroaxial volvulus' above.)

●Forty percent of gastric volvuli present acutely without prior symptoms as a complete gastric outlet obstruction or as a partial gastric outlet obstruction. Acute gastric volvulus is a surgical emergency and is associated with a high mortality if not promptly recognized and treated. Borchardt's triad, which is abdominal or chest pain, vomiting, and an inability to pass a nasogastric tube, occurs in as many as 70 percent of acute cases. (See 'Clinical presentations' above.)

●We evaluate suspected acute gastric volvulus initially with plain film, followed by computed tomography (CT). Classic findings on plain abdominal radiograph include a single large spherical gas bubble in the upper abdomen and a paucity of air in the distal bowel. These clinical features may be absent in patients with chronic gastric volvulus, and further imaging, such as CT or upper gastrointestinal series, will be needed. (See 'Diagnostic evaluation' above.)

●Patients diagnosed with acute gastric distention due to gastric volvulus require immediate gastric decompression by placing a nasogastric tube (algorithm 1). This is initially attempted at the bedside but, if unsuccessful, may require endoscopic assistance or surgical intervention. In addition to nasogastric decompression, initial management also includes fluid resuscitation and correction of electrolyte abnormalities. (See 'Initial treatment' above and "Gastric outlet obstruction in adults", section on 'Management'.)

●Patients with a stomach that cannot be decompressed by nasogastric tube or endoscopically, CT evidence of gastric perforation or mediastinal contamination, shock or hypotension refractory to resuscitation, or severe sepsis require immediate open abdominal exploration following resuscitation and gastric decompression. Such patients likely have gastric necrosis and/or perforation, which can only be salvaged by surgical resection for septic source control. Endoscopic evaluation can help diagnose or exclude gastric ischemia in patients with partial clinical responses to decompression. (See 'Subsequent care' above and 'Immediate surgery' above.)

●Clinically stable patients with acute presentation, but whose symptoms improve with resuscitation and gastric decompression (most patients), and patients with chronic presentation can avoid immediate surgery but undergo planned definitive treatment after completing diagnostic evaluation and medical/anesthetic risk assessment. Definitive treatment can be accomplished with endoscopic or surgical (open or laparoscopic) techniques (algorithm 1). (See 'Delayed definitive treatment' above.)

•For symptomatic patients with primary gastric volvulus (acute or chronic), we suggest gastric fixation to anchor the stomach to the abdominal wall to minimize recurrence rather than observation (Grade 2C). The approach (laparoscopic gastropexy or percutaneous endoscopic gastrostomy [PEG] tubes) depends on patient condition and clinician preference. (See 'Primary gastric volvulus' above.)

•For symptomatic patients with secondary gastric volvulus, we suggest surgical repair of the anatomic defect (eg, paraesophageal hernia) in addition to gastric fixation, rather than observation or gastric fixation alone (Grade 2C). Surgical repair appears to reduce the risk of future recurrence. For patients with significant medical comorbidities, not repairing the anatomic defect is an acceptable alternative, provided that gastric derotation and fixation have been accomplished (laparoscopic or endoscopic). (See 'Secondary gastric volvulus' above.)

•Patients who have gastric volvulus but medical comorbidities that preclude surgery require a less invasive approach, usually endoscopic derotation and PEG tube placement. However, endoscopic repair does not address anatomic abnormalities and thus is less optimal for patients with secondary volvulus. (See 'Poor surgical candidates' above.)