Gastric volvulus is an uncommon disorder caused by twisting of the stomach on itself. This occurs above the diaphragm in approximately two-thirds of patients and below the diaphragm in the remainder. In the former setting, patients have a congenital or acquired defect in the diaphragm, typically a paraesophageal hiatus hernia. In the majority of patients (60%), the stomach twists on its long axis (organoaxial) but twisting can also occur along the short axis (mesenteroxial) or may encompass both components. Symptoms can be acute or chronic depending on the degree of twist, the development of gastrointestinal obstruction and the degree of vascular compromise. Acute symptoms include severe pain in the upper abdomen or lower chest, unproductive retching and an inability to pass a nasogastric tube into the stomach (Borchardt's triad). With chronic volvulus, typical symptoms include epigastric discomfort, fullness, nausea and vomiting, particularly after meals. Investigations usually include chest radiographs, endoscopy and barium studies. Chest radiographs may show a gas-filled viscus in the lower chest while, with endoscopy, normal landmarks are lost, twisting of gastric folds may be observed and visualization of the pylorus can be difficult or impossible. Barium or gastrograffin studies are usually diagnostic and show a variety of abnormalities including the ‘upside-down’ stomach in a large paraesophageal hernia. In relation to therapy, endoscopic correction of volvulus has been reported but most patients should proceed to laparoscopic or open fixation of the stomach and repair of any associated diaphragmatic hernia. The early recognition and treatment of acute gastric volvulus has resulted in a substantial fall in mortality.

The patient illustrated below was an 80-year-old man who was investigated because of a 4-week history of intermittent abdominal pain, anorexia and recurrent vomiting after meals. There was mild tenderness on palpation over the upper abdomen. Upper gastrointestinal endoscopy revealed twisting and narrowing of the body of the stomach (Figure 1). The appearance raised the strong possibility of gastric volvulus and a barium study was performed. The fundus of the stomach was located below the diaphragm while the body of the stomach was in an ‘upside-down’ position in the thoracic cavity (Figure 2). The appearance was typical of organoxial rotation of the stomach within a large paraesophageal hernia. The patient refused surgery but continues to have intermittent symptoms at follow-up after 12 months.