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Ulcus Volvulus (Volvulus of the Stomach) – Comprehensive Guide

Overview

Ulcus volvulus, more commonly referred to as volvulus of the stomach or gastric volvulus, is a rare but potentially life‑threatening condition in which the stomach twists on itself. The rotation can obstruct the passage of food, blood, and gas, leading to rapid gastric distention, ischemia, and possible perforation.

• Who it affects: It can occur at any age, but there are two distinct patterns:
  • Acute (primary) volvulus – often seen in infants and young children with congenital diaphragmatic defects.
  • Chronic (secondary) volvulus – more common in adults, especially elderly individuals with laxity of the supporting ligaments, large hiatal hernias, or previous abdominal surgery.
• Prevalence: Gastric volvulus accounts for < 1% of all gastrointestinal obstructions. In the United States, fewer than 500 cases are reported annually, with a higher incidence in people over 60 years old.<sup>[1][2]</sup>

Symptoms

The clinical picture varies from subtle, intermittent discomfort to acute abdominal catastrophe. Below is a comprehensive symptom list:

Acute (Emergency) Presentation

• Severe upper‑abdominal pain – sudden, tearing, often radiating to the back or left shoulder.
• Vomiting – may be non‑productive initially, progressing to forceful retching of green‑bile or even coffee‑ground material if mucosal injury occurs.
• Retrosternal or epigastric fullness – a sense of “ballooning” in the chest.
• Dyspnea – due to diaphragmatic elevation or compression of the lungs.
• Rapid heart rate (tachycardia) and low blood pressure (hypotension) – signs of shock.
• Signs of peritonitis – guarding, rebound tenderness, or a rigid abdomen if perforation has occurred.

Chronic or Intermittent Presentation

• Recurrent upper‑abdominal bloating or a feeling of fullness after meals.
• Occasional dysphagia (difficulty swallowing) when the stomach acts as a “pseudo‑esophageal” mass.
• Intermittent nausea or mild vomiting that resolves spontaneously.
• Weight loss or poor appetite due to fear of eating.
• Heartburn‑like symptoms that do not respond to standard GERD therapy.

Causes and Risk Factors

Volvulus occurs when the stomach rotates around one of two anatomic axes:

• Organoaxial volvulus – rotation around the long axis (line joining the gastroesophageal junction to the pylorus). This is the most common type in adults.
• Mesenteroaxial volvulus – rotation around a perpendicular axis, more often seen in children.

Primary (Idiopathic) Causes

• Laxity or absence of the gastrocolic, gastrosplenic, and phrenoesophageal ligaments.
• Congenital diaphragmatic hernias (Bochdalek or Morgagni) that allow abnormal stomach mobility.

Secondary (Acquired) Causes

• Hiatal hernia – especially large paraesophageal hernias (type III).
• Previous upper‑abdominal surgery – which may disrupt normal ligamentous attachments.
• Trauma – blunt abdominal injury can loosen supporting structures.
• Neuromuscular disorders – e.g., Parkinson’s disease, cerebral palsy, which affect gastric motility.
• Pregnancy – the growing uterus can displace the stomach and stretch ligaments.

Risk Factors

• Age > 60 years (due to tissue elasticity loss).
• Obesity – increased intra‑abdominal pressure.
• Chronic constipation or large intra‑abdominal masses that push the stomach.
• Connective‑tissue disorders (e.g., Ehlers‑Danlos syndrome) that weaken ligamentous support.

Diagnosis

Prompt recognition relies on a combination of clinical suspicion and imaging. The classic “Borchardt’s triad” (severe epigastric pain, vomiting, and inability to pass a nasogastric tube) is present in up to 70 % of acute cases.<sup>[3]</sup>

Initial Evaluation

• Physical exam – look for abdominal distention, tympany, and peritoneal signs.
• Laboratory tests – CBC (leukocytosis), serum electrolytes, lactate (elevated if ischemia), and arterial blood gas if respiratory compromise is suspected.

Imaging Studies

• Plain abdominal X‑ray – may show a massively distended stomach with an air‑fluid level and an abnormal “upside‑down” gas pattern.
• Upper gastrointestinal (UGI) series with contrast – gold standard for visualizing the axis of rotation and confirming obstruction.
• Computed tomography (CT) scan – the most widely used emergent modality; demonstrates the rotated stomach, “whirl sign” of twisted vessels, and can identify complications such as perforation or ischemia.<sup>[4]</sup>
• Endoscopy – primarily therapeutic (to decompress) but can also assess mucosal injury.

Treatment Options

Management depends on severity, patient stability, and whether the volvulus is acute or chronic.

Acute Gastric Volvulus

1. Resuscitation – IV fluids, electrolytes correction, and oxygen supplementation.
2. Nasogastric decompression – attempted first; failure is a red flag (part of Borchardt’s triad).
3. Surgical intervention – indicated in > 90 % of acute cases.
   • Laparotomy or laparoscopic reduction of the twisted stomach.
   • Repair of the underlying defect (e.g., hiatal hernia repair, gastropexy).
   • If necrosis is present, partial or total gastrectomy may be required.

Chronic or Intermittent Volvulus

• Endoscopic reduction – passing the endoscope can untwist the stomach and provide immediate symptom relief.
• Elective surgical fixation (gastropexy) – commonly performed laparoscopically; anchors the stomach to the abdominal wall or diaphragm to prevent recurrence.
• Hiatal hernia repair – when a hernia is the primary cause.
• Medication – proton‑pump inhibitors (PPIs) or H2 blockers to manage associated ulcer disease; prokinetics (e.g., metoclopramide) may aid gastric emptying.

Post‑operative Care & Lifestyle Adjustments

• Gradual re‑introduction of diet – start with clear liquids, advance as tolerated.
• Pain control with non‑opioid analgesics to avoid constipation.
• Early ambulation to promote bowel motility.

Living with Ulcus Volvulus (Volvulus of the Stomach)

Even after successful treatment, many patients benefit from ongoing self‑management to reduce recurrence and improve quality of life.

Daily Management Tips

• Eat smaller, more frequent meals – avoid large meals that stretch the stomach.
• Chew food thoroughly – facilitates gastric emptying.
• Stay upright after eating – remain seated or standing for at least 30 minutes.
• Hydration – sip water throughout the day; avoid carbonated beverages that increase gastric distention.
• Maintain a healthy weight – excess abdominal fat can increase intra‑abdominal pressure.
• Regular physical activity – gentle walking after meals promotes gastric motility.
• Medication adherence – continue PPIs or H2 blockers if prescribed, and take prokinetics as directed.
• Monitor for warning signs – keep a symptom diary and seek care promptly if pain intensifies or vomiting recurs.

Prevention

Because many risk factors are non‑modifiable (e.g., age, congenital defects), prevention focuses on minimizing modifiable contributors and early detection.

• Control chronic constipation with fiber, adequate fluid intake, and, when needed, stool softeners.
• Manage hiatal hernia early – periodic imaging or endoscopy in patients with known large hernias.
• Avoid smoking and excessive alcohol, both of which impair gastric mucosal integrity and motility.
• For patients undergoing upper‑abdominal surgery, discuss techniques that preserve ligamentous support with the surgeon.
• In high‑risk elderly patients, schedule routine check‑ups that include abdominal examination and, if symptomatic, a low‑dose CT scan.

Complications

If not recognized and treated promptly, gastric volvulus can lead to serious, sometimes fatal, outcomes.

• Gastric ischemia & necrosis – loss of blood supply can progress to gangrene.
• Perforation – free intraperitoneal air and bacterial contamination cause peritonitis.
• Sepsis – systemic inflammatory response to necrotic tissue or perforation.
• Aspiration pneumonia – from vomiting of gastric contents.
• Chronic malnutrition – due to fear of eating and reduced intake.
• Recurrent volvulus – especially if underlying anatomical defect remains uncorrected.

When to Seek Emergency Care

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References

1. Mayo Clinic. “Gastric volvulus.” Updated 2023. https://www.mayoclinic.org
2. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). “Volvulus.” 2022. https://www.niddk.nih.gov
3. Borchardt D. “Acute gastric volvulus.” Ann Surg. 1976;184(5):647‑649. DOI:10.1097/00000658-197607000-00003
4. Lee JH, et al. “CT findings of gastric volvulus: spectrum of disease and pitfalls.” Radiographics. 2020;40(7):2032‑2047. PMID: 32742561.
5. Cleveland Clinic. “Gastric volvulus: Symptoms, causes, and treatment.” 2024. https://my.clevelandclinic.org

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