Gastric Volvulus with Perforation: Causes, Pathophysiology, Imaging, Treatment, and Prognosis

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Keywords: Gastric volvulus with perforation, gastric volvulus, stomach torsion, acute abdomen, gastrointestinal emergency, gastric perforation, CT imaging gastric volvulus

Introduction

Gastric volvulus is a rare but life-threatening condition characterized by an abnormal rotation of the stomach along its anatomical axes, potentially resulting in obstruction, ischemia, necrosis, and perforation. When gastric volvulus is complicated by perforation, the risk of mortality increases substantially, making timely diagnosis and surgical intervention imperative.

Although first described in the 19th century, gastric volvulus remains a diagnostic challenge due to its variable clinical presentation and overlap with other abdominal emergencies. This column provides a comprehensive discussion of etiology, pathophysiology, epidemiology, clinical presentation, imaging findings, treatment, and prognosis of gastric volvulus with perforation, supported by the provided case material and current literature.

Case Overview

A patient presented with acute abdominal pain and was subsequently diagnosed with gastric volvulus with perforation. Imaging findings from chest radiography and CT scans confirmed the diagnosis. The provided images serve as illustrative references throughout this discussion.

Etiology and Causes

The etiology of gastric volvulus can be broadly categorized into primary and secondary causes:

  1. Primary gastric volvulus results from congenital or acquired laxity of the gastric ligaments (gastrosplenic, gastrophrenic, gastrohepatic, and gastrocolic).

  2. Secondary gastric volvulus occurs due to underlying conditions such as:

    • Hiatal hernia

    • Diaphragmatic eventration or paralysis

    • Paraesophageal hernia (Types III and IV)

    • Post-surgical changes (e.g., esophagectomy with gastric pull-through)

    • Intrathoracic displacement due to trauma or congenital defects

In the case provided, the volvulus occurred secondary to diaphragmatic herniation, leading to torsion, ischemia, and perforation.

Pathophysiology

Gastric volvulus occurs when the stomach rotates more than 180 degrees, leading to outflow obstruction and vascular compromise. Two primary types are described:

  • Organoaxial volvulus (OAV): The stomach rotates along its long axis (cardia-to-pylorus). This is the most common type in adults and is often associated with paraesophageal hernia.

  • Mesenteroaxial volvulus (MAV): The stomach rotates along its short axis (greater-to-lesser curvature). This type is more common in children and is often related to congenital anomalies.

A mixed type can also occur, involving features of both OAV and MAV.

When torsion exceeds 180 degrees, the blood supply is compromised, leading to ischemia, necrosis, and perforation. In the presented case, perforation was confirmed by the presence of extraluminal gas seen on CT imaging.

Epidemiology

  • Gastric volvulus is rare, with fewer than 500 cases reported in the literature annually.

  • It affects both pediatric and adult populations, but is more common in older adults due to ligament laxity and association with hiatal hernia.

  • Organoaxial volvulus accounts for approximately two-thirds of cases.

  • Perforation is uncommon but represents the most severe complication, with a reported mortality of up to 30–50% if not promptly managed.

Clinical Presentation

The clinical presentation varies between acute and chronic/intermittent forms.

Acute gastric volvulus (surgical emergency)

  • Severe epigastric pain

  • Intractable retching with minimal vomitus

  • Inability to pass a nasogastric tube beyond the gastroesophageal junction

This triad, known as Borchardt’s Triad, is considered pathognomonic for acute gastric volvulus.

Chronic/intermittent gastric volvulus

  • Recurrent upper abdominal discomfort

  • Gastroesophageal reflux symptoms

  • Early satiety and bloating

  • Intermittent dysphagia

In the presented case, the patient demonstrated acute abdominal pain with imaging confirmation of perforation, consistent with the fulminant presentation of gastric volvulus.

Imaging Features

Plain Radiographs

[Figure 1] Chest A-P radiograph: Abnormally enlarged mediastinal silhouette with a retrocardiac air-fluid level.

[Figure 2] Lateral view: A rounded, lucent mass with double air-fluid levels behind the heart, suggesting intrathoracic stomach displacement.

Computed Tomography (CT)

[Figure 3] Contrast-enhanced CT (axial, coronal, sagittal): Herniation of the stomach and proximal duodenum into the thorax, twisting at the diaphragmatic hiatus, associated with small extraluminal gas pockets.

CT interpretation: Dilated, displaced stomach with signs of perforation, mesenteric stretching, and mediastinal shift. CT remains the gold standard for diagnosis, enabling visualization of volvulus, herniation, ischemia, and perforation.

Differential Diagnosis

  • Hiatal hernia

  • Post-surgical gastric pull-through

  • Epiphrenic diverticulum

  • Mediastinal mass

However, the presence of torsion, intrathoracic stomach, and extraluminal gas strongly favors gastric volvulus with perforation.

Treatment

Management is dictated by acuity and complications.

  1. Acute volvulus with perforation:

    • Emergent laparotomy or laparoscopy

    • Detorsion of the stomach

    • Resection of necrotic or perforated tissue

    • Gastropexy (fixation of the stomach to prevent recurrence)

  2. Chronic or recurrent cases:

    • Elective surgical repair

    • Percutaneous endoscopic gastrostomy (PEG) for fixation

    • Hernia repair if secondary to a hiatal or diaphragmatic defect

Non-operative management is not recommended in cases of perforation, as mortality is exceedingly high.

Prognosis

  • Without perforation, the Prognosis is favorable with timely surgical intervention.

  • With perforation, Mortality may approach 30–50% due to peritonitis, mediastinitis, and septic shock.

  • Long-term outcomes depend on the underlying etiology and the adequacy of surgical fixation in preventing recurrence.

Quiz Section

Quiz 1: What abnormal structure is seen on the chest radiograph ([Figure 1])?
A. Esophagus
B. Stomach
C. Pericardium
D. Left lower lobe
E. Liver

Quiz 2: Which statement is TRUE regarding CT findings ([Figure 3])?
A. The entire stomach herniates into the chest.
B. The proximal duodenum also herniates into the chest.
C. No extraluminal gas is present.
D. The liver has shifted into the thorax.

Quiz 3: Which clinical triad is characteristic of acute gastric volvulus?
A. Rigler’s Triad
B. Borchardt’s Triad
C. Charcot’s Triad
D. Beck’s Triad

Answer & Explanation

1. Answer: B. Stomach. Explanation: The radiograph reveals an intrathoracic stomach with an air-fluid level, consistent with gastric volvulus.

2. Answer: A and B are true; C is false.. Explanation: CT demonstrated both the stomach and proximal duodenum in the thoracic cavity, with small extraluminal gas pockets indicating perforation.

3. Answer: B. Borchardt’s Triad. Explanation: The classic triad includes severe epigastric pain, intractable retching without vomitus, and inability to pass a nasogastric tube.

Conclusion

Gastric volvulus with perforation is a rare but devastating gastrointestinal emergency. Early recognition using imaging modalities, particularly CT, is essential for accurate diagnosis and surgical planning. Prompt intervention significantly reduces morbidity and mortality. Awareness of this condition, particularly in elderly patients with hiatal hernia, can lead to improved clinical outcomes.

References

[1] M. P. Federle, “Gastric volvulus,” StatDx, 2011. [Online]. Available: http://www.statdx.com

[2] C. M. Peterson, J. S. Anderson, A. K. Hara, J. W. Carenza, and C. O. Menias, “Volvulus of the gastrointestinal tract: appearances at multimodality imaging,” Radiographics, vol. 29, pp. 1281–1293, 2009.
[3] A. Rashid, S. S. Nazir, and S. Bhat, “Acute gastric volvulus: a rare but real surgical emergency,” International Journal of Surgery Case Reports, vol. 12, pp. 26–28, 2015.
[4] M. Wu, Y. Chiu, and H. Wu, “Acute gastric volvulus with perforation: case report and literature review,” World Journal of Gastroenterology, vol. 21, no. 43, pp. 12498–12503, 2015.
[5] C. Gourgiotis, G. Vougas, E. Germanos, A. Baratsis, “Acute gastric volvulus: diagnosis and management,” Asian Journal of Surgery, vol. 29, no. 4, pp. 257–259, 2006.
[6] P. Chau, A. Law, and H. Lai, “Laparoscopic repair of gastric volvulus associated with paraesophageal hernia,” Surgical Endoscopy, vol. 25, pp. 3574–3578, 2011.
[7] H. Rashid and S. Khan, “Gastric volvulus: a rare entity,” Journal of Medical Case Reports, vol. 3, no. 1, pp. 1–3, 2009.

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