Gastric volvulus is a rare but serious condition where the stomach rotates abnormally around its longitudinal or transverse axis, leading to obstruction and potential ischemia. It occurs when anatomical or functional factors allow the stomach to twist on itself, often resulting in acute abdominal pain, vomiting, and inability to pass gas or food.
The primary mechanism involves loss of normal fixation of the stomach within the abdominal cavity. This allows the organ to rotate freely, especially during changes in posture or increased intra-abdominal pressure. The most common forms are organoaxial (rotation along the long axis) and mesenteroaxial (rotation around the short axis), each with distinct underlying causes.
Understanding the causes of gastric volvulus requires examining both congenital and acquired factors. Congenital anomalies such as a wide gastrohepatic ligament or incomplete fusion of the dorsal mesentery predispose individuals to torsion. Acquired causes include diaphragmatic hernias, particularly paraesophageal hernias, which disrupt normal gastric positioning and increase risk. Other contributors include delayed gastric emptying due to diabetes mellitus or post-surgical adhesions.
Normal stomach anatomy includes attachments via the gastrosplenic, gastrohepatic, and gastrophrenic ligaments. These structures stabilize the organ. When any of these ligaments are elongated or lax, the stomach becomes mobile. Rotation typically begins at the cardia or fundus and progresses through the body and antrum.
Once rotation exceeds 180 degrees, the gastric outlet becomes obstructed. Blood flow to the distal stomach may be compromised, leading to necrosis if untreated. The condition can progress rapidly-symptoms often appear within hours of onset. Delayed diagnosis increases mortality risk.
A 2021 study published in *World Journal of Gastroenterology* reported that 68% of gastric volvulus cases presented with sudden onset epigastric pain, vomiting, and inability to pass flatus. In 32% of cases, patients had prior history of hiatal hernia or previous abdominal surgery-key red flags for clinicians.
Causes of gastric volvulus fall into two categories: congenital and acquired. Congenital causes involve developmental abnormalities in fetal life that affect the fixation of the stomach. These include persistent left-sided superior vena cava, absent or hypoplastic gastrosplenic ligament, and malrotation of the gut.
Acquired causes are more common in adults and include:
Patients with Marfan syndrome or Ehlers-Danlos syndrome have higher rates of connective tissue laxity, which contributes to weakened abdominal wall support and increased risk of volvulus. A 2019 case series in *Annals of Surgery* documented five patients with Ehlers-Danlos who developed gastric volvulus following minor exertion or eating large meals.
Gastric volvulus is frequently mistaken for acute pancreatitis, peptic ulcer disease, or small bowel obstruction due to overlapping symptoms. However, imaging reveals the key difference: a dilated stomach with a "double bubble" sign on upright abdominal X-ray or CT scan, indicating obstruction and rotation.
Unlike pyloric stenosis, which presents with projectile vomiting and visible peristalsis, gastric volvulus causes bilious emesis and early satiety. The presence of air-fluid levels in the upper abdomen on plain film suggests obstruction, but only cross-sectional imaging confirms rotation.
A critical distinction lies in the timing of symptom onset. Volvulus typically presents acutely-within minutes to hours-whereas chronic conditions like gastritis or GERD develop over days. A patient reporting sudden inability to eat or drink, accompanied by severe epigastric pain, should prompt immediate imaging.
A 67-year-old woman with a history of type 2 diabetes and a known paraesophageal hernia presented to the emergency department with 6 hours of worsening epigastric pain, inability to vomit despite retching, and distension. She had not passed stool or flatus in 12 hours.
Initial abdominal X-ray showed a large air-filled structure in the upper abdomen with no clear bowel gas pattern. A CT scan revealed the stomach rotated 360 degrees around its long axis, with the greater curvature displaced upward and the lesser curvature downward. The fundus was located near the diaphragm, consistent with organoaxial volvulus.
She underwent emergency laparotomy. The surgeon found the stomach twisted at the gastrohepatic ligament. After detorsion, the stomach was repositioned and secured with gastropexy to prevent recurrence. Post-op recovery was uneventful. Pathology confirmed intact mucosa, indicating timely intervention.
This case illustrates that even in elderly patients with comorbidities, gastric volvulus remains a surgical emergency requiring rapid diagnosis and treatment. Delay beyond 6 hours increases risk of perforation and sepsis.
Many assume gastric volvulus affects only children or young adults. In reality, adult-onset cases are more common, especially in patients over 50 with pre-existing abdominal pathology. A 2020 review in *Surgery Today* found that 54% of diagnosed cases occurred in patients aged 50-80.
Another misconception is that volvulus only affects the stomach. While isolated gastric volvulus is rare, it can coexist with sigmoid volvulus or jejunal volvulus in patients with generalized intestinal malrotation. The combination increases surgical complexity and mortality.
Gastric volvulus is not always symptomatic. Some patients present incidentally on imaging for unrelated reasons. A 2022 retrospective analysis in *American Journal of Roentgenology* identified 12 asymptomatic cases among 150 patients undergoing CT for suspected abdominal pathology-highlighting the need for vigilance in high-risk populations.
Sudden onset of severe epigastric pain, inability to pass gas or stool, and persistent vomiting require immediate evaluation. Patients with known hiatal hernias, prior abdominal surgeries, or neurological disorders affecting GI motility are at higher risk.
Gastric volvulus causes span developmental defects, acquired structural changes, and functional impairments. Recognizing the triggers-especially in older adults with comorbidities-can lead to faster intervention and better survival. Prompt recognition and surgical correction remain essential for managing this rare but life-threatening condition.