Gastric volvulus

Dr Ian Bickle and Dr Jeremy Jones et al.

Gastric volvulus is a specific type of volvulus that occurs when the stomach twists on its mesentery. It should be at least 180° and cause bowel obstruction to be called gastric volvulus. Merely gastric rotation on its root is not considered gastric volvulus.

Organo-axial volvulus is more common in adults, responsible for 60% of presentations. Mesentero-axial volvulus is more common in children.

Patients may present with the classic triad of Borchardt, which is:

  • severe sudden epigastric pain
  • intractable retching without vomiting
  • inability to pass a nasogastric tube

Chronic symptoms are more common in patients with mesentero-axial volvulus.

Both subtypes are surgical emergencies and warrant treatment

  • more common of the two types in adults (2/3 of cases)
  • commonly occurs in the setting of trauma or para-oesophageal hernia
  • stomach is rotated along its long axis (along the cardiopyloric line, which is drawn between the cardia and the pylorus)
  • mirror image of normal anatomy can occur with reversal of the greater and lesser curves 
    • antrum rotates anterosuperiorly
    • fundus rotates posteroinferiorly
  • complete (>180º) present with obstruction or ischemia
  • incomplete  rotation (<180º) also called organo-axial position of the stomach, usually asymptomatic
  • less common in adults, but is more common than organo-axial volvulus in the paediatric population (59% of gastric volvulus)
  • rotation around short axis from the lesser to greater curvature (i.e. perpendicular to the cardiopyloric line)
    • usually incomplete, <180°
  • displacement of antrum above gastro-oesophageal junction; stomach appears upside-down with the antrum and pylorus superior to the fundus and proximal body
  • coincides with the axis of mesenteric attachment and is associated with severe obstruction and strangulation
  • less associated with diaphragmatic defect
  • plain films may show an intrathoracic stomach with two air fluid levels 1
  • chest radiograph
    • intrathoracic; upside-down stomach
      • retrocardiac fluid level
  • abdominal radiograph; when performed with the patient upright
    • double air-fluid level
    • large, distended stomach
    • collapsed small bowel
  • distended stomach in left upper quadrant extending into thorax
  • inversion of stomach
  • volvulus with >180° twist causes luminal obstruction
  • incomplete or absent entrance of contrast material into and/or out of stomach is indicative of acute obstructive volvulus
  • "beaking" may be demonstrated at point of twist
  • mesenteroaxial: antrum and pylorus lie above gastric fundus
  • appearance depends on points of torsion, extent of gastric herniation, and final positioning of stomach
  • linear septum may be visible within the gastric lumen which corresponds to the site of torsion
  • entire stomach may be herniated (type IV paraoesophageal hernia (PEH)) or only part of it (type III PEH)
    • both can result in
      • volvulus
      • obstruction
      • ischaemia
    • ischaemia seen as lack of contrast enhancement of gastric wall, with or without pneumatosis

Surgical repair, including stomach detorsion and gastropexy, is the main treatment modality for gastric volvulus. Detorsion may be performed open or laparoscopically. If the stomach is strangulated or necrotic, gastric resection may be required.

  • epiphrenic diverticulum
  • postoperative state of the stomach
  • hiatal hernia
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Article information

rID: 6170
Section: Pathology
Synonyms or Alternate Spellings:
  • Mesenteroaxial volvulus
  • Mesentero-axial volvulus
  • Organoaxial volvulus
  • Organo-axial volvulus
  • Stomach volvulus

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Cases and figures

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    Figure 1: organo-axial axis
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    Organoaxial gastr...
    Case 1: organo-axial
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    Figure 2: mesentero-axial axis
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    Organoaxial gastr...
    Case 2: organo-axial
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    Case 3: with diaphragmatic rupture
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    Diaphragmatic her...
    Case 4: with diaphragmatic hernia
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    Case 5: organo-axial
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    Case 6: organo-axial
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    Case 7: mesentero-axial - plain film
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    Case 7: mesentero-axial - CT
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    Case 8: mesentero-axial
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    Image from an upp...
    Case 9: mesentero-axial
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    Case 10: organoaxial volvulus
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    Case 11: organoaxial volvulus
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    Case 12: volvulus and perforation
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    Case 13: Incomplete mesentero-axial volvulus of the stomach
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    Case 14: mesentero-axial gastric volvulus
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