Bhori Singh, a 45-year-old male, presented with abdominal pain, distension and inability to pass flatus or stool for the past few days. Examination and investigations revealed acute intestinal obstruction likely due to gastric volvulus or perforation peritonitis. He underwent an exploratory laparotomy with gastropexy where gastric volvulus was found and repaired by suturing the stomach to the abdominal wall. Post-operatively, he recovered well and was discharged on the 8th day. Gastric volvulus is the twisting of the stomach and can be acute or chronic. Treatment involves endoscopic or surgical reduction and fixation of the stomach to prevent recurrence.

1. Dr. Sudarshan
Under Guidance of
Dr. B. L. Yadav
Assistant Professor,
Upgraded Department of Surgery

2. History
Name: Bhori singh
Age & sex: 45 yrs ,male
Resident :Baroli ,Bharatpur
DOA:05/01/2013
Clinical presentation
Pain abdomen: last 3 days
Abdominal distention: last 3 days
Not passing flatus motion: last 2 days
No h/o fever
No h/o vomiting

3. Cont..
Past history:
 No h/o similar complaint
 No h/o previous surgery
 No h/o DM, TB, COPD, Hypertension , Bronchial
Asthma
Personal history
 Smoker
 Tobacco chewer
 Non alcoholic
 Normal bowel bladder habits

4. Examination
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Conscious
Oriented
Afebrile
Pulse-92/min
B.P-100/70 mmHg
No pallor
No L.N Pathy
No icterus
No clubbing
No pedal oedema

5. P/A
Inspection:
 Abdomen distended with fullness present in upper abdomen
 No visible pulsation , peristalsis
Palpation:
 Abdomen is tense, tender
 Guarding present
 No Rigidity
Percussion:
 Tympanic note present
 Normal liver dullness and span
 No shifting dullness
Auscultation:
 Bowel sounds absent

6. Investigations
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HB- 11.6 gm/dl
TLC- 1400 /mm3
PLT- 1.35 lakh/ml
Serum urea/creatinine- 87/2.0 mg/dl
S.Total bilirubin-1.2 mg/dl
Direct- 0.5 mg/dl
Indirect- 0.7 mg/dl
SGOT/SGPT- 70/18
Serum amylase-175.0 u/lt
Serum electrolytes- wnl
X-Ray FPA- Multiple air fluid level with large single
stomach gas shadow

7. Provisional diagnosis:
 Acute intestinal obstruction
 Perforation peritonitis
Plan:
 Exploratory Laparotomy

8. Procedure performed
 Exploratory laparotomy with Gastropexy

9. Per operative photos
cranial
R
L
caudal

10. Cont…
CRANIAL
R
L

11. Cont..
cranial
R
L

12. Cont..
Cranial
Caudal

13. Contd..
Stomach Fixed to
Diaphragm &
AnteroLateral
Abdominal Wall
With Silk

14. Post operative follow up
 Vitals monitoring
 Input /output monitoring
 Chest physiotherapy
 Skin stitches removal-7th post op. day
 Discharge-8th post op. day

15. Discussion
 Definition
Gastric volvulus or volvulus of stomach a twisting of
all or part of the Stomach by more than 180 degrees
with obstruction of the flow of material through the
stomach, variable loss of blood supply and possible
tissue death.

16. Cont..
 Very uncommon clinical entity
 First described by Berti in 1866
 Seen in both children and elderly people
 Rare below fifth decades of life

17. Classification of gastric volvulus
On the basis of:
1)OnsetAcute
Chronic
2)Axis of rotation Organoaxial
Mesentroaxial
Combined

18. Gastric volvulus
1. Organoaxial(along longitudinal axis-MC)
a)Acute presentation
b)associated with diaphragmatic defects
c)more common in adults
d)vascular compromise more common
2. Mesentroaxial (along vertical axis)
a) recurrent episodes of pain abdomen
b) Diaphragmatic defects are not seen
c) more common in children
3. Combined

19. Diagrammatic representation
Organoaxial
Mesentroaxial

20. Aetiology
 Type 1 or Idiopathic gastric volvulus
comprises two thirds of cases and is presumably due to
abnormal laxity of the
gastrosplenic*, gastrocolic*, gastrophrenic and
gastrohepatic* ligaments.

21. Cont..
 Type 2 or secondary
Type 2 gastric volvulus is found in one third of patients and is
usually associated with congenital or acquired abnormalities
that result in abnormal mobility of the stomach
 Diaphragmatic defect
Eventration
Paraoesophagial hiatal defect
Trauma
Paralysis
 Congenital bands and adhesions
 Intestinal malrotation
 Pyloric stenosis and gastric distension
 Colon distention

22. AETIOLOGY

23. Clinical features
 Pain abdomen (acute in onset)
 Recurrent retching with little vomitus
 Inability to pass a Ryles tube
OTHERS
 Abdominal pain
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Vomiting
Upper GI bleed
Dysphagia
Gastro oesophageal reflux
Respiratory symptoms
Altered bowel habit
Borchardts
Triad

24. Investigations
 X Ray FPA- Gas filled viscus in chest and or upper
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abdomen, multiple air fluid levels,
Barium contrast studies :sensitive and specific
Upper GI Endoscopy: both diagnostic and
therapeutic
USG
CT scan abdomen and MRI

25. X-ray findings in gastric volvulus

26. Contd …

27. Barium meal:
Organoaxial volvulus
Before surgery
After surgery

28. Mesentricoaxial Gastric volvulus

29. Endoscopy view:

30. USG:
 Peanut sign in a case of chronic gastric volvulus.
 The ultrasonographic features consist of a constricted
segment of stomach, with 2 dilated segments located
above and below the constricted part, akin to a peanut.
 In several case reports, however, the ultrasonographic
evaluation of gastric volvulus showed normal findings.

31. CT image:

32. Advantage of CT Scan
 detection of gastric pneumatosis and
pneumoperitoneum, suggestive of necrosis and
perforation, respectively
 detection of predisposing factors, e.g. diaphragmatic
defects or hernias, dense adhesions
 detection of other abnormalities associated with
gastric volvulus, viz. wandering spleen, intrathoracic
kidney, malrotation with asplenia
 excluding other extra-gastric or vascular causes of
gastric ischaemia

33. Limitation of Techniques
 Plain radiography may demonstrate findings that are
indistinguishable from those that are produced by
other causes of gastric atony or obstruction.
However, the modality is useful for excluding other
causes of the patient's symptoms, such as
pneumoperitoneum or pneumothorax.
 Barium study is highly sensitive and specific.
However, the diagnosis may be missed in cases of
intermittent torsion.

34. Treatment
 Aims:
1) Reduction of volvulus
2) Gastric fixation
3) Repair of predisposing factor
 Apporach:
Open
Endoscopic
Laproscopic
Combined (endoscopic + laproscopic)

35. Cont..
Open surgery:
 Diaphragmatic hernia repair
 Division of bands
 Gastropexy
 Partial gastrectomy(In case of necrosis)
 Gastrojejunostomy
 Repair of eventration of diaphragm

36. Surgical procedures
Anterior suture gastropexyThe stomach along the
gastro colic omentum is
suspended to the anterior
abdominal wall
Partial gastrectomy –
Indicated if a portion of the
stomach is gangrenous

37. Cont..
Endoscopic :
Reduction
 Alpha loop maneuver
 J type maneuver
With or without gastrostomy(for fixation of stomach)
(PEG)

38. PEG Tube

39. Cont..
Laproscopic
 Reduction of volvulus
 Anchoring fundus of stomach to diaphragm and
greater curvature of stomach to anterior abdominal
wall
 Repair of diaphragmatic defects
 fundoplication

40. Cont..
Combined approach
 Described by Arben Beqiri in 1997
 Less time consuming
 Endoscopic T-fasteners are used instead of PEG for
anchoring stomach

41. T-fastener system

42. Method for providing apposition of two
bodily walls
a) forming a puncture site through the two walls;
b) inserting an access cannula into the puncture site;
c) passing a guide tube through the access cannula, the guide tube
retroflexing after passing beyond a distal end of the access
cannula;
d) positioning a distal end of the guide tube proximate one of the
bodily walls;
e) passing a flexible puncturing device through the guide tube and
puncturing the two bodily walls at a second location;
f) connecting a fastener to the puncturing device;
g) retracting the puncturing device to draw the fastener through
the two bodily walls at the second location; and
h) securing the fastener to maintain apposition of the two walls at
the second location.

43. Follow up
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Clinical:
Reflux symptoms
Recurrence
Removal of PEG Tube
Imaging:
Contrast study

44. Complications of volvulus
 Strangulation
 Necrosis
 Perforation of stomach
 Gastrointestinal haemorrhage
 Cardiopulmonary failure

45. Complications related to PEG Tube
 Wound infection
 Peritonitis
 Peristomal leakage
 Dislodgement
 Bowel perforation
 Gastrocolic fistula

46. Association
 Wandering spleen
 Congenital diaphragmatic hernia
 Diaphragmatic eventration

47. Chronic gastric volvulus
 Patient presents with recurrent episodes of vague
abdominal pain and discomfort
 Bloating
 Surgery is only indicated if the episodes of pain are
severe and disabling
 T/t of choice- conservative
 Operation of choice-anterior gastropexy