Gastric volvulus is an abnormal rotation of the whole or part of the stomach. The terminology does not distinguish between ‘torsion’, which is simple rotation, and true volvulus, which implies luminal obstruction. Little attention is paid to the difference, although volvulus is more dangerous because of the risk of necrosis and perforation. Berti first described the condition in 1866: he reported the postmortem findings in a 60-year-old female of ‘an entire mass of organs making two complete horizontal turns, the oesophagus and the duodenum were interlaced’. Subsequently Berg described the successful operative treatment of gastric volvulus in two patients in 1895 and 1896. The detailed review and observations in 1930 by Buchanan clarified the anatomical variants associated with this rare condition, and aetiological factors were clearly addressed by Tanner (1968).

The stomach is maintained in its normal position by four ligaments. The lesser curve and liver are joined by the gastrohepatic ligament, the greater curve is attached to the spleen and transverse colon by the gastrosplenic and gastrocolic ligaments, and the cardia is held fixed by the phrenicoesophageal ligament. Some form of ligament abnormality (extreme laxity, absence, or disruption) is essential to allow rotation; the direction of rotation is determined by which ligaments are lax and which points remain relatively fixed. The condition can be broadly classified into two groups.

The pylorus and oesophagogastric junction remain relatively fixed and rotation occurs around a line between these two. There are two subgroups of this condition. In the first (posterior organoaxial) the stomach rotates through 180° left to right, such that the anterior surface is facing backward. The posterior surface presents under the abdominal wall and is covered by the mesocolon when, as is usual, the transverse colon has participated in the rotation. In some patients the colon remains in an inferior position due to extreme laxity or rupture of the gastrocolic ligament. Thus two further subgroups of posterior organoaxial volvulus can be defined, dependent on the position of the stomach in relation to the colon, the infracolic and the supracolic. The spleen and pancreas may also be displaced with the stomach.

The second, and rarer type is anterior organoaxial volvulus. The greater curve passes backwards and presents in the lesser sac, resulting in the anteriorly facing posterior gastric wall being covered by the gastrohepatic ligament. Rotation cannot usually proceed beyond 180°. This type of volvulus is often partial. In a number of patients the cardia remains in place while only the antral portion of the stomach rotates. This abnormality may be seen in association with an hourglass stomach in which a large antral pouch has formed, which is able to pivot on its margins.

Rotation from right to left around a vertical line at right angles to the axis of rotation of organoaxial volvulus. The cardia remains in position and a mobile pylorus rotates anteriorly or posteriorly until it is in juxtaposition with the cardia. The anterior wall is sharply kinked and folded on itself, while the posterior wall is covered by a lax gastrocolic ligament. The right half of the transverse colon is carried up in front of the volvulus towards the splenic flexure. The remainder of the abdominal organs remain undisplaced.

Organoaxial volvulus is most common in adults, accounting for 50 per cent of reported cases. Mesenteroaxial volvulus accounts for 29 per cent, and a combination is reported in 2 per cent. The remainder have not been classified. In infants and children, however, mesenteroaxial volvulus accounts for 53 per cent of reported cases, with organoaxial volvulus in 35 per cent and a combination in 5 per cent.

Although ligamentous laxity must be present there are a number of conditions that are associated with the development of volvulus. These can be divided into three groups.

1.Abnormalities of the stomach

2.Abnormalities of the surrounding viscera

3.Rotation of the stomach to fill an abnormal space

These include conditions that produce acute or chronic distension. Pyloric stenosis and duodenal obstruction result in elongation of the ligaments and gastric ptosis. A heavy bolus lying in the lower part of the greater curve may act as a lower fixed point around which mesenteroaxial rotation can occur. In infants, absence or attenuation of ligaments may be a result of failure of fusion of fetal visceral mesenteries, and the presence of congenital bands may predispose to volvulus.

Splenomegaly, producing elongation of the gastrosplenic ligament, has been cited as an aetiological factor. Other conditions that are associated include volvulus of the transverse colon and midgut, and dislocation and hypoplasia of the left lobe of the liver.

The stomach may enter an abnormal space in association with a para-oesophageal hernia, in other forms of hiatus or diaphragmatic hernia, or with congenital or acquired eventration of the diaphragm. Approximately 65 per cent of children with gastric volvulus have an associated eventration or hernia of the left hemidiaphragm. In a study of infants younger than 12 months, 81 per cent had one of these anomalies. In adults the most common association is an organoaxial volvulus in a large paraoesophageal hernia: in one series, 15 per cent of 138 surgically treated para-oesophageal hernias contained an intrathoracic gastric volvulus.

The clinical presentation of gastric volvulus is entirely dependent on whether it is acute with complete obstruction and/or strangulation, or chronic and associated with partial obstruction and no ischaemia. An acute event may occur in a stomach that has had a chronic volvulus.

A diagnostic triad of vomiting followed by non-productive retching, localized epigastric pain, and failure to pass a nasogastric tube are symptoms which indicate obstruction of the gastrooesophageal junction. True vomiting is unlikely to occur: instead frothy white material and saliva is regurgitated. In the initial phase there is likely to be few abdominal physical signs, although gastric distension may occur and signs of peritonitis and perforation follow strangulation.

The classic triad is often difficult to interpret in infants, since pain and retching are non-specific, and the failure to pass a nasogastric tube may be difficult to interpret. In older patients the condition can be difficult to distinguish from myocardial ischaemia: an electrocardiogram is often helpful. The plain radiograph appearance is often dramatic in both adults and children, with a hugely dilated stomach and a double fluid level on the erect film. In patients with eventration or diaphragmatic hernias the inverted stomach may be seen in the chest. Contrast studies are often unhelpful, since retching renders the study dangerous and will only demonstrate obstruction with no contrast entering the stomach.

Chronic or recurrent volvulus presents a clinical picture that may be mistaken for gallbladder disease, gastritis, or peptic ulceration. Pain is often mild and episodic, although bouts of upper abdominal colic and vomiting can occur. Dysphagia may be present if the oesophagogastric junction is distorted, and eructation of swallowed air can be difficult. After meals gastric peristalsis may be noisy and cause embarrassment, a situation that is relieved by lying down. There are no characteristic physical signs. In contrast to acute volvulus radiographs using contrast media may demonstrate the abnormality.

Acute volvulus requires immediate preoperative resuscitation followed by urgent laparotomy. The stomach must be derotated, gangrenous areas resected, and the stomach fixed with repair of any associated defects. Although passage of a nasogastric tube will deflate the stomach and occasionally produce spontaneous reduction, it may perforate the oesophagus or stomach, and persistent attempts are particularly hazardous in infants. The treatment of chronic volvulus can proceed more slowly, with careful preoperative evaluation and assessment of the risks of surgery.

An upper midline incision provides adequate access in adults; a transverse incision is required in children. If the stomach is massively distended decompression with needle, trochar, or gastrotomy aspiration is necessary prior to reduction. If a gastronomy is performed it should be closed immediately, since the gastric opening may migrate to an inaccessible position on reduction. Careful inspection of the stomach for areas of ischaemia, including the posterior wall through the lesser sac, is essential. Resection of the stomach and surrounding organs, in particular the transverse colon, is required if they are non-viable. Once the stomach is reduced the remainder of the procedure aims to prevent a recurrence.

Conditions predisposing to volvulus should be dealt with directly, and this may be all that is required. In patients without a predisposing cause or where the causative defect does not lend itself to surgical correction, or when this is inappropriate in an ill frail patient, some form of gastropexy should be performed. The simplest involves the formation of a gastrotomy: this technique is particularly suitable in children, tethering the stomach to the anterior abdominal wall. However, recurrence is common following simple fixation. It must be remembered that most infants have a diaphragmatic defect that requires correction. Gastroenterostomy and partial gastrectomy should be restricted to patients with peptic ulcer disease, who require definitive surgery for this. Tanner recommended gastropexy with colonic displacement in patients with eventration of the left diaphragm. The colon is detached from the stomach and placed under the left hemidiaphragm to fill the space; the lesser curve of the stomach is then sutured to the edge of the liver and falciform ligament. This form of gastropexy carries the lowest recurrence rate. An operation devised by Opolzer, comprising a side-to-side fundus to antral gastrogastrostomy is not to be recommended, since it allows the volvulus to remain and oesophageal and pyloric obstruction can still occur. Following surgery, prolonged gastric stasis may occur and a gastrostomy is useful to maintain decompression.

In modern surgical practice this is a rare disorder, but it can produce profound circulatory disturbance and death. It is akin to paralytic ileus and the same factors are often the cause. Acute gastric dilatation may occur following gastric or abdominal surgery, trauma, retroperitoneal haematoma, hypoxia, or electrolyte disturbance. It appears to be slightly more common in women and children, and may be seen in sedated patients receiving oxygen via nasal catheters.

The clinical presentation is sufficiently distinct to allow differentiation from paralytic ileus. The patient develops tachycardia, and may become shocked; hiccups are common and may be followed by belching, and enormous and effortless vomiting. The vomitus has a characteristic appearance that was described by Hamilton Bailey as the colour of ‘storm water of a peat laden stream’. There may be upper abdominal distension. The condition can be suspected clinically and the distended stomach can often be outlined by percussion. The diagnosis is confirmed by the passage of a nasogastric tube and the aspiration of copious volumes of fluid. A plain abdominal or chest radiograph will demonstrate a hugely distended stomach. The condition can be fatal since vomitus may be aspirated and the hypovolaemia from fluid loss is considerable.

The stomach is decompressed by nasogastric suction and the fluid and electrolyte loss replaced intravenously. An underlying cause should be sought and corrected if present, but this is generally not the case, and following decompression for several days spontaneous recovery of gastric function occurs.

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