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Gastric Volvulus

Clinical Subject Page

Gastric Volvulus

Gastric volvulus is a rare condition in which the stomach rotates more than 180° along either the
organoaxial or mesenteroaxial axis, resulting in gastric outlet obstruction and potential vascular
compromise

Also called

Stomach volvulus

ICD-10

K56.2

Specialty

Gastroenterology

Onset

Acute

Reviewed

July 2026

On This Page

Overview

Gastric volvulus is a surgical emergency characterized by abnormal rotation of the stomach. The
rotation can obstruct gastric emptying and compromise blood supply, leading to ischemia, necrosis,
or perforation. Acute gastric volvulus classically presents with Borchardt triad and requires urgent
surgical treatment

Etiology & Risk Factors

Primary Causes

  • Laxity or absence of gastric supporting ligaments (idiopathic)

  • Congenital defects of the gastric ligaments

Secondary Causes (More Common)

  • Paraesophageal hiatal hernia (most common in adults)

  • Diaphragmatic hernia

  • Eventration of the diaphragm

  • Diaphragmatic paralysis

  • Previous upper abdominal or thoracic surgery

  • Adhesions

  • Gastric tumors (rare)

  • Splenic abnormalities (e.g., wandering spleen)

Risk Factors

  • Older age

  • Large paraesophageal hiatal hernia

  • Congenital diaphragmatic defects

  • Previous abdominal surgery

  • Connective tissue laxity

  • Gastric ligament abnormalities

  • Trauma involving the diaphragm (rare)

Pathophysiology

1. The stomach rotates >180° along the organoaxial or mesenteroaxial axis.
2. Gastric outlet obstruction develops.
3. Blood supply may become compromised.
4. Progressive ischemia may lead to necrosis or perforation if untreated.

Clinical Presentation

  • Acute gastric volvulus (Borchardt triad):
    • Severe epigastric pain and distention
    • Retching without vomiting
    • Inability to pass a nasogastric tube
    Chronic gastric volvulus:
    • Intermittent symptoms of gastric outlet obstruction

History Taking

  • Ask about:
    • Sudden severe epigastric pain
    • Retching without vomiting
    • Abdominal distention
    • Previous hiatal or paraesophageal hernia
    • Intermittent episodes of gastric outlet obstruction (if chronic)

Physical Examination

Assess for:
• Epigastric distention
• Severe epigastric tenderness
• Signs of gastric outlet obstruction
• Signs of peritonitis or sepsis if perforation or ischemia is suspected

Investigations

Initial Tests

  • Complete blood count (CBC)

  • Electrolytes and renal function tests

  • Serum lactate (assess for ischemia)

  • Arterial blood gas (if critically ill)

Diagnostic Investigations

Chest and Abdominal X-ray

May show:

  • Large gas-filled stomach

  • Abnormal gastric position

  • Air-fluid level

CT Abdomen with IV Contrast – Preferred Imaging

  • Investigation of choice

  • Confirms gastric rotation

  • Identifies the type of volvulus

  • Detects ischemia, perforation, or associated diaphragmatic defects

Upper Gastrointestinal Contrast Study (Barium Swallow)

  • Demonstrates abnormal gastric rotation

  • Shows gastric outlet obstruction

  • Useful in stable patients

Upper Gastrointestinal Endoscopy (EGD)

  • Assesses gastric mucosal ischemia

  • May assist in endoscopic decompression

  • Excludes other upper GI pathology

Diagnosis

  • Diagnosis is usually based on:
    • Characteristic clinical presentation
    • Abdominal X-ray findings
    • CT chest and abdomen confirming gastric rotation

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Management

  • 1. Initial Stabilization

    • Assess Airway, Breathing, and Circulation (ABC)

    • Keep the patient nil by mouth (NPO)

    • Intravenous fluid resuscitation

    • Correct electrolyte abnormalities

    • Nasogastric tube decompression (if possible)

    • Analgesia and antiemetics

    2. Definitive Treatment

    Surgical Management (Preferred)

    Indicated for most patients, especially acute volvulus.

    Options include:

    • Reduction (detorsion) of the stomach

    • Gastropexy (fixation of the stomach)

    • Repair of diaphragmatic or hiatal defects

    • Resection of necrotic stomach if ischemia is present

    Laparoscopic surgery is preferred when feasible.

    Endoscopic Management

    Consider in:

    • High-risk surgical patients

    • Temporary decompression before surgery

    • Selected chronic gastric volvulus

    Endoscopy may reduce the volvulus but does not reliably prevent recurrence.

    3. Conservative Management

    Reserved for:

    • Asymptomatic or minimally symptomatic chronic gastric volvulus

    • Patients who are not candidates for surgery

    Includes:

    • Observation

    • Dietary modification

    • Management of underlying conditions

    • Close follow-up

    4. Follow-Up

    • Monitor for recurrence

    • Assess nutritional status

    • Treat underlying hiatal or diaphragmatic abnormalities

    • Repeat imaging if symptoms recur

Complications

• Gastric strangulation
• Gastric ischemia
• Gastric necrosis
• Gastric perforation
• Sepsis

Prognosis

  • Prognosis depends on prompt recognition and surgical intervention.
  • Early treatment generally
    results in good outcomes, whereas delayed diagnosis increases the risk of ischemia, perforation,
    sepsis, and mortality.

Key Points / Clinical Pearls

• Gastric volvulus is rotation of the stomach >180°.
• It may occur along the organoaxial or mesenteroaxial axis.
• Common causes include lax gastric ligaments, paraesophageal hernia, gastric ulcer, and gastric
carcinoma.
• Acute gastric volvulus presents with Borchardt triad.
• Abdominal X-ray and CT are the main diagnostic imaging studies.
• Initial management includes gastric decompression.
• Definitive treatment is urgent surgical detorsion with gastropexy.
• Major complications include ischemia, necrosis, perforation, and sepsis.