62. Gastric volvulus, gastroptosis, bezoars and foreign bodies

1. Definition

• Gastric volvulus → rotation of the stomach of more than 180° around one of its axes, causing obstruction and risk of strangulation
• Gastroptosis → downward displacement of the stomach (visceroptosis), often with other organs
• Bezoar → mass of undigested material that collects in the stomach or bowel
• Foreign body → swallowed (ingested) object, by accident or on purpose

2. Epidemiology

• Gastric volvulus → rare; peak age over 50 (adults), 15–20% in children under 1 year (with diaphragmatic defects)
• Gastroptosis → thin, tall women; often with general visceroptosis
• Bezoars → rare; most after gastric surgery (vagotomy, gastrectomy) or with gastroparesis; trichobezoars in young women with psychiatric illness
• Foreign bodies:
  • 80% in children (6 months–3 years): coins, button batteries, magnets, toys
  • Adults → food bolus, dentures, fish and chicken bones; prisoners, psychiatric patients, drug packers
  • 80–90% pass spontaneously; 10–20% need endoscopy; about 1% need surgery

3. Aetiology and risk factors

Gastric volvulus

• Primary (about 1/3) → lax or absent gastric ligaments (gastrosplenic, gastrohepatic, gastrocolic, gastrophrenic)
• Secondary (about 2/3) → anatomical defects:
  • Paraoesophageal hiatus hernia (most common)
  • Diaphragmatic eventration, traumatic rupture, CDH
  • Asplenia, wandering spleen, adhesions

Gastroptosis

• Weak abdominal wall, rapid weight loss, multiple pregnancies, thin body build

Bezoars

• Phytobezoar → plant fibre (persimmons, citrus, celery); after gastric surgery, diabetes
• Trichobezoar → hair; trichotillomania and trichophagia; young women
• Pharmacobezoar → drugs (sucralfate, antacids, extended-release tablets)
• Lactobezoar → milk curd; premature babies on concentrated feeds
• Others → shellac, plastics, tissue paper
• Risk → poor gastric emptying, low acid, poor chewing, no teeth

Foreign bodies

• Children → putting things in the mouth
• Adults → dentures, alcohol, mental illness, learning disability, prisoners, body packers (drug packets)
• Narrowing → oesophageal stricture, eosinophilic oesophagitis, ring

4. Pathogenesis

• Volvulus:
  1. Stomach twists over 180°
  2. Closed-loop obstruction at the cardia and pylorus
  3. Venous congestion, then arterial cut-off
  4. Ischaemia, necrosis, perforation (5–28%)
• Gastroptosis → stomach hangs low; slow emptying; dragging pain
• Bezoar → grows slowly; can obstruct the pylorus; trichobezoar may extend into the small bowel as a "tail" (Rapunzel syndrome); pressure ulcers and bleeding
• Foreign bodies → narrow points:
  • Cricopharyngeus (most common hold-up point)
  • Aortic arch and left main bronchus
  • Lower oesophageal sphincter
  • Pylorus, duodenal C-loop, ligament of Treitz, ileocaecal valve
• Button battery → electric current makes hydroxide at the mucosa → liquefactive necrosis within 2 hours; perforation, aortic or tracheal fistula
• Two or more magnets → attract across bowel walls → pressure necrosis, fistula
• Sharp objects → perforation (15–35% if not removed)

5. Classification

Gastric volvulus

• By axis:
  • Organoaxial (about 2/3) → around the long axis (cardia to pylorus); greater curve flips up; adults, with hiatus hernia
  • Mesenteroaxial (about 1/3) → around the short axis (lesser to greater curve); antrum rotates up; children, chronic
  • Combined (rare)
• By onset → acute, chronic (intermittent)
• By cause → primary, secondary

Bezoars

• Phyto, tricho, pharmaco, lacto, others

Foreign bodies

• Blunt, sharp-pointed, long (over 6 cm), button batteries, magnets, food bolus, drug packets

6. Clinical picture

Symptoms

• Acute gastric volvulus → Borchardt's triad:
  1. Severe sudden epigastric pain and distension
  2. Retching with little or no vomiting
  3. Inability to pass an NG tube
• Chronic volvulus → intermittent epigastric fullness, early satiety, bloating, chest pain after meals
• Gastroptosis → dragging pain after meals, relieved by lying down; bloating, constipation
• Bezoar → early satiety, nausea, vomiting, epigastric pain, weight loss; may be silent; bleeding, obstruction
• Foreign body:
  • Oesophagus → dysphagia, odynophagia, drooling, inability to swallow saliva, chest pain, retching
  • Children → may be silent; refuse feeds, drool, stridor, cough
  • Stomach and below → usually no symptoms; pain, fever, peritonitis if perforated

Signs

• Volvulus → epigastric distension; shock and peritonitis if strangulated
• Bezoar → movable epigastric mass (trichobezoar), patchy hair loss, foul breath
• Foreign body → neck tenderness, surgical emphysema (perforation), peritonism

7. Diagnosis

• Volvulus:
  • Chest and abdominal X-ray → large gas-filled viscus in the upper abdomen or chest, double air-fluid level
  • CT → transition point, position, ischaemia, hiatus hernia
  • Contrast meal → type of volvulus (chronic)
  • Endoscopy → may untwist; check mucosa
• Gastroptosis → barium meal standing: low J-shaped stomach (greater curve below the iliac crests)
• Bezoar → endoscopy (diagnostic and therapeutic); CT (mottled mass with gas); barium meal (filling defect)
• Foreign body:
  • Plain X-ray neck, chest and abdomen (AP and lateral) → most metal objects
  • Button battery → double ring (halo) on AP view, step-off on lateral (coin has none)
  • CT → radiolucent objects (bones, plastic), perforation, drug packets
  • No barium (makes endoscopy hard; aspiration risk)
  • Metal detector in children (coins)

8. Differential diagnosis

• Volvulus → acute pancreatitis, perforated ulcer, myocardial infarction, oesophageal rupture, mesenteric ischaemia
• Gastroptosis → functional dyspepsia, gastroparesis
• Bezoar → gastric tumour, gastric outlet obstruction
• Foreign body → oesophageal spasm, globus, food impaction on a stricture or cancer

9. Treatment

Conservative

• Acute volvulus:
  1. Resuscitation, analgesia
  2. NG decompression (if it passes)
  3. Endoscopic reduction in selected patients without ischaemia; percutaneous endoscopic gastrostomy (PEG) to fix it (gastropexy) in unfit patients
• Gastroptosis → reassurance, small frequent meals, lie down after meals, abdominal support, physiotherapy of abdominal muscles; surgery almost never
• Bezoars:
  • Phytobezoar → enzyme dissolution (cellulase, papain) or Coca-Cola lavage, prokinetics (metoclopramide)
  • Endoscopic fragmentation and removal (snare, basket, lithotripsy)
  • Treat the cause → gastroparesis, diet, psychiatric care (trichobezoar)
• Foreign bodies:
  • Blunt object in the stomach → wait; X-ray weekly; most pass in 4–6 days
  • Endoscopy timing:
    • Emergency (within 2–6 hours) → button battery in the oesophagus, oesophageal obstruction (cannot swallow saliva), sharp object in the oesophagus
    • Urgent (within 24 hours) → sharp or long objects in the stomach, magnets, oesophageal coins, food bolus
    • Elective → blunt objects stuck in the stomach over 3–4 weeks
  • Food bolus → glucagon or effervescent agents (weak evidence); endoscopy with push or retrieval; then biopsy for eosinophilic oesophagitis or stricture
  • Endoscopy with an overtube for sharp objects
  • Battery in the stomach in a child → remove if symptoms, large (20 mm or more) or under 6 years with magnet; otherwise X-ray in days
  • Honey or sucralfate for a swallowed button battery in a child over 1 year, while waiting (within 12 hours)
  • Body packers → conservative with laxatives and watchful care; no endoscopy (packet rupture → drug overdose)

Surgical

• Acute volvulus with ischaemia, perforation or failed decompression → emergency laparotomy or laparoscopy:
  1. Reduce the stomach (decompress first with a needle if needed)
  2. Resect necrotic stomach → partial or subtotal gastrectomy
  3. Correct the cause → repair the hiatus hernia or diaphragm
  4. Gastropexy → anterior wall fixed to the abdominal wall, or gastrostomy tube
• Chronic volvulus → elective laparoscopic hiatus hernia repair with gastropexy
• Bezoar → surgery (gastrotomy) for large trichobezoars, Rapunzel syndrome, obstruction, perforation, failed endoscopy; check the small bowel
• Foreign body → surgery for perforation, obstruction, bleeding, failed endoscopy, sharp object not moving for 3 days, magnets with signs, ruptured drug packets or obstruction in body packers

10. Complications

• Volvulus → gastric necrosis, perforation, shock; mortality 30–50% for acute strangulated cases (historical), about 15% today
• Bezoar → gastric ulcer, bleeding, gastric outlet obstruction, perforation, small bowel obstruction, recurrence
• Foreign body:
  • Oesophageal perforation → mediastinitis
  • Button battery → oesophageal necrosis, tracheo-oesophageal fistula, aorto-oesophageal fistula (fatal bleeding), strictures, vocal cord palsy
  • Magnets → fistula, perforation, volvulus
  • Aspiration, airway obstruction
  • Drug packer → fatal overdose