Gastric Volvulus

Abdominal Pain and Distension • Xray of the Week 2016 • Week #51

An 83 year old female with multiple comorbidities presented to the Emergency Department with abdominal pain, distention, and altered mental status. What is the diagnosis?

Figure 1. Sagittal (A) and axial (B) contrast enhanced CT.

Figure 2. Sagittal (A) and axial (B) contrast enhanced CT of mesentero-axial gastric volvulus. Massively dilated stomach, herniating into the thoracic cavity via the gastroesophageal hiatus. The stomach descends into the abdominal cavity before herniating back intrathoracically and the duodenum finally descends intraabdominally with the remainder of the GI tract. Green arrow: GE junction Blue arrow: antrum.

Discussion:

Gastric volvulus is an uncommon cause of abdominal pain and may be a surgical emergency which requires prompt communication with the clinical team and treatment (1,2). The Borchardt triad of intractable retching, sudden epigastric abdominal pain and inability to pass a nasogastric tube (3) is classically described, but patients may also present with more chronic symptoms. Unlike the sigmoid colon and cecum, the stomach is an uncommon site for volvulus. There are two types of volvulus, organo-axial and mesentero-axial, which are differentiated based on the axis of rotation.

Organo-axial volvulus represents an 180◦ twist along the cardiapyloric/long axis of the stomach with the greater curvature often displaced superior to the lesser curvature. This type is more common, representing approximately 2/3 of cases (1) of gastric volvulus, and commonly associated with hiatal hernias and traumatic events such as diaphragmatic rupture (4). With less than 180◦ of rotation, patients are usually asymptomatic and this should be termed organo-axial positioning of the stomach rather than volvulus. Although this may predispose to future volvulus, it is unclear if these patients require treatment.

Mesentero-axial volvulus is a twist along the short axis of the stomach, along the mesenteric attachment (2). As seen in this case, the antrum presents above the gastroesophageal junction (Figs. 1 and 2). Although less common in the adult population (3), this tends to present with a more acute symptomatology. Due to the higher association with strangulation of the gastric blood supply, this is a surgical emergency. If diagnosed early, treatment may only require surgical repair. However, late diagnosis may result in gastric necrosis, necessitating a gastrectomy (1,3).

References: 1. Peterson CM, Anderson JS, Hara AK, Carenza JW, Menias CO. Volvulus of the gastrointestinal tract: appearances at multimodality imaging. RadioGraphics 2009;29(5):1281–1293. 2. Menuck L. Plain film findings of gastric volvulus herniating into the chest. AJR Am J Roentgenol. 1976;126 (6): 1169-74. 3. Guniganti P, Bradenham CH, Raptis C et-al. CT of Gastric Emergencies. Radiographics. 2015;35 (7): 1909-2 4. Lee NK, Kim S, Jeon TY, Kim HS, Kim DH, Seo HI et al. Complications of congenital and developmental abnormalities of the gastrointestinal tract in adolescents and adults: evaluation with multimodality imaging. Radiographics 2010: 30(6):1489–1507.

Alexandra (Sasha) Roudenko, MD is originally from Siberia, Russia and grew up in New York City. After graduating magna cum laude from Barnard College - Columbia University as a chemistry major, she was invited to join the prestigious Phi Beta Kappa Society. She then received her MD degree from New York University School of Medicine. Dr. Roudenko is currently a third year radiology resident at Mount Sinai West - St. Luke's and has developed a passion for body imaging. She is particularly interested in body MRI and plans on pursuing the subspecialty throughout her career. In 2016, Dr. Roudenko was awarded a fellowship in the introduction to academic radiology program at ARRS.

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Kevin M. Rice, MD is president of Global Radiology CME and serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. Dr. Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator.

Follow Dr. Rice on Twitter @KevinRiceMD

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Carol L Hilfer, MD is an assistant professor of Radiology at The Mount Sinai Hospital - Mount Sinai St. Luke's and Mount Sinai West