Presentation

Predispositions: The vast majority of cases are seen >50yrs of age, but 10-20% of patients are under 1yrs. Most commonly related to hiatus hernias, but also laxity of gastric ligaments.

History/Exam :

• Borcsharts Triad (70% of cases)
  • Acute epigastric pain
  • Persistent retching with inability to vomit
  • Inability/difficulty passing a NG tube (however this can vary on type of rotation)
• Haematemesis:
  • Is also a common presentation likely due Mallory-Weiss tears due to retching and/or tissue damage from the strangulation of the stomach.
• Epigastric/Abdominal pain:
  • Pain develops quickly as can bloating/fullness.
  • Tenderness however, can develop latter
• Observations:
  • In the early stages observations likely “normal”
  • However, as things worsen the patient observations worsen and develop shock
    • Unfortunately, if recognised at this point mortality is much higher

Diagnostics:

• CXR:
  • This may be your only clue initially!
  • Gastric bubble and fluid level
  • Often seen behind heart as in the picture (radiopedia) – the resent case at our trust CXR similar but bubble and fluid level seen behind the heart and to left.
• CT:
  • CT is the diagnostic test of choice.
• Bloods:
  • Initially can be “normal”
  • However, a septic picture will likely develop

Management

The most important thing is early recognition. Mortality is high even when caught early and only worsens with time.

Once suspected:

• Arrange CT
• Early Surgical Input
  • Medical/Gastrointestinal input may also be needed if presenting with an UGIB
  • ICU input may also be required
• Symptomatic/Supportive Mangment
  • Analgesia
  • Fluids
  • Antibiotics (high risk of sepsis)
  • Antiemetic
  • NG tube can be attempted but be gentle (in 70% of cases it wont pass)

References

• Radiopedia – Gastric Volvulus
• STATPearls – Gastric Volvulus
• Fatal Gastric Volvulus – Forensic perspective
• Acute Gastric Volvulus – A rare cause of haematemesis