gastric volvulus , an entity seen in both pediatric and adult patients , occurs when the stomach twists upon itself .
this event may be transient , producing few if any symptoms , or may lead to obstruction or even ischemia and necrosis .
pare described the first case of gastric volvulus in 1579 in a patient with diaphragmatic injury from a sword wound .
acute gastric volvulus in pediatric and adult patients has been reported but chronic organo - axial gastric volvulus with diaphragmatic eventration has not been reported .
this report describes a rare case of gastric volvulus with a review of the literature .
he had a feeling of fullness and discomfort in the upper abdomen for 2 months .
twenty years ago , he was told that his chest radiography , performed due to routine survey for military service , was abnormal .
but he had received no specific measures since then and he had been relatively healthy .
a thorough review of symptoms was performed but did not disclose any respiratory or cardiovascular symptoms . on clinical examination , he appeared not acutely ill looking and his body temperature was 36c , blood pressure 120/70 mmhg , respiratory rate 24/min .
auscultation of the chest showed diminished breathing sound at the left lung base and heart sound was normal .
no abnormalities were observed in cbc , liver chemistry , serum amylase and stool examination .
the chest radiograph showed the left hemidiaphragm to be located at an unusually high intercostal space with large air - fluid level ( figure 1 ) .
upper gastrointestinal series demonstrated the typical appearance of an organo - axial volvulus of the stomach ( figure 2 ) .
the barium - filled stomach was twisted on an axis from the pylorus to the esophagus .
the patient refused surgical or endoscopic correction of the volvulus and has been followed in the outpatient clinic for more than 6 months without symptom aggravation .
the stomach is relatively fixed at the esophageal hiatus and the pylorus by the four gastric ligaments . the gastrophrenic ligament and the retroperitoneal attachment of the second part of the duodenum provide the superior and inferior fixation .
the gastrohepatic ligament tethers the lesser curve , the gastrocolic ligament connects the stomach to the transverse colon , and the gastrosplenic ligament tethers the greater curve .
the clinical symptoms depend upon the extent or degree of rotation , obstruction and associated defect .
borchard s triad of pain , violent retching and inability to pass a nasogastric tube6 should lead to a strong clinical suspicion of acute gastric volvulus .
an acute volvulus is an emergency situation , with either obstruction or strangulation of the stomach and requires expeditious surgery . in comparison ,
this explains why the diagnosis is often delayed in the elderly or after complication has occurred .
. gastro - esophageal reflux may give rise to epigastric pain , which is intermittent during the periods of engorgement or gastric emptying .
gastric ulceration is caused by localized ischemia and acidity within the herniated stomach or mucosal congestion due to venous obstruction of the herniated stomach .
angina - like pain and electrocardiographic abnormalities may make the differential diagnosis difficult in the elderly .
the diagnosis is confirmed by the presence of a large , unusual gas - filled viscus in the chest or abdomen on plain radiographs . if necessary , a barium swallow study can define the anatomic changes more exactly . on barium examination ,
the characteristic findings are 1 ) esophagogastric junction lying lower than normal , 2 ) reversal of the greater and lesser curvatures , 3 ) pylorus pointing downward , 4 ) greater curvature crossing the esophagus , 5 ) two air - fluid levels and lowering of the gastric fundus .
secondary gastric volvulus is more frequent than idiopathic volvulus , therefore the diagnosis of gastric volvulus can be made after a thorough search for possible causative factors .
these conditions have been reported as follows ; para - esophageal hernia , traumatic rupture of the diaphragm , eventration of the diaphragm and phrenic nerve injury . in infants and children , 15 ( 33% ) among 46 patients with gastric volvulus had diaphragmatic eventration .
organo - axial volvulus is commonly associated with diaphragmatic hernia and usually manifests as an acute event .
diaphragmatic eventration is suggested when a part or all of the hemidiaphragm is located at an unusually high level in the thorax .
it does not refer to a defect or hole in the diaphragm with discrete edges , but rather to a diffuse or localized bulging of the diaphragm itself .
acquired lesions are usually related to phrenic nerve injury , which may be diverse in origin . radiological investigation combined with fluoroscopy of the diaphragm
our patient showed no diaphragmatic movement during respiration , so he had complete left hemidiaphragmatic eventration .
acute gastric volvulus and symptomatic chronic gastric volvulus require operative treatment . if the volvulus is secondary , definitive treatment must include correction of the associated abnormalities .
this is done by advancing the endoscope just past the point of torsion , turning and locking the tip of the instrument , and rotating it 180 degrees . with rapid diagnosis and modern treatment
, the rate of mortality from acute gastric volvulus is now about 15% to 20% .
if the stomach is strangulated , the mortality rate of emergency surgery is 4060% . in recognized cases of chronic gastric volvulus
 gastric volvulus occurs when the stomach rotates about its longitudinal axis ( organo - axial volvulus ) , or about an axis joining the lesser and greater curvatures ( mesentero - axial volvulus ) . 
 primary gastric volvulus , making up one third of cases , occurs when the stabilizing ligaments are too lax as a result of congenital or acquired causes . 
 secondary gastric volvulus , making up the remainder of cases , occurs in association with a paraesophageal hernia or other congenital or acquired diaphragmatic defects . 
 while gastric volvulus may occur acutely , especially in children , it may not be clinically apparent and discovered incidentally . 
 the authors present a case of chronic organo - axial volvulus of the stomach secondary to left hemidiaphragmatic eventration with a review of the relevant literature . 