Clinical Imaging 34 (2010) 344–347

Radiological features of acute gastric volvulus in adult patients

Hassan Al-Balasa,⁎, Mohammed Bani Hanib, Hamzi Z. Omaria

aDepartment of Radiology, King Abdullah University Hospital, P. O. Box 6300001, Irbid, 21110, JordanbDepartment of Surgery, King Abdullah University Hospital, P. O. Box 6300001, Irbid, 21110, Jordan

Received 8 August 2009; accepted 9 September 2009

Abstract

Objective: To evaluate the radiological features of acute gastric volvulus in adults and correlate these features with operative findings.Materials and Methods: The clinical, radiological and operative findings of five adult patients (four males and one female with mean age of50.4 years) who presented or referred to King Abdullah University hospital over 4 year’s period with symptoms of acute gastric volvuluswere reviewed retrospectively. All patients underwent upper gastrointestinal barium study and two of them had computed tomographic (CT)scans preoperatively. The radiological features demonstrated on upper gastrointestinal barium exams and CT scans were analyzed andcompared with operative findings. Results: Radiological and operative findings revealed organo-axial gastric volvulus in all patients in ourstudy. All of them had associated diaphragmatic defect or hiatal hernia. The upper gastrointestinal barium studies demonstrated the classicradiological features of organo-axial volvulus. CT done on two of our patients confirmed the diagnosis. Conclusion: Upper gastrointestinalbarium study is an accurate way to diagnose and characterize acute gastric volvulus in adult patients. CT scan can also be used to diagnosethis clinical entity.© 2010 Elsevier Inc. All rights reserved.

Keywords: Acute gastric volvulus; Upper gastrointestinal Barium study; CT

1. Introduction

Acute gastric volvulus is a rare acute surgical emergencythat involves abnormal rotation of the stomach along one ofits axis by more than 180° resulting in closed loopobstruction. Delay in the diagnosis can lead to catastrophicconsequences including gastric necrosis and strangulation[1]; therefore, early recognition of the fairly characteristicradiological features of this entity can be lifesaving [2].

Beri was the first to fully describe this acute surgicalentity in 1866 on autopsy. Rosselet in 1920 fully describedits radiological features. Thereafter, this entity had beendescribed more frequently and recognized as an importantetiology of acute abdomen.

Gastric volvulus has been classically classified into eitherorgano- or mesentero-axial types. When the stomach rotatesaround an axis line connecting the gastro-esophageal

⁎ Corresponding author. Department of Radiology, King AbdullahUniversity Hospital, Irbid, Jordan.

E-mail address: albalas@yahoo.com (H. Al-Balas).

0899-7071/$ – see front matter © 2010 Elsevier Inc. All rights reserved.doi:10.1016/j.clinimag.2010.02.001

junction and pylorus, the term organ-axial volvulus isused. Mesentero-axial gastric volvulus is used when thestomach rotates around an imaginary transverse lineconnecting the middle of lesser and greater curvatures ofthe stomach.

We described the radiological features of acute gastricvolvulus seen on upper gastrointestinal Barium studies andcomputed tomographic (CT) scans. This description is aimedat better understanding of these features so that earlyradiological diagnosis can be achieved.

2. Materials and methods

The clinical presentations and radiological features of alladult patients who underwent surgical repair for acute gastricvolvulus between 2002 and 2006 at our hospital wereretrospectively reviewed.

Over 4 year's period, a total of 5 cases of acute gastricvolvulus either presented or were referred to our hospital.Patients with chronic presentations were excluded fromthis study.

Table 1Clinical features of the patients included in the study

Age (years) Gender Signs and Symptoms Associated pathology

29 M Vomiting and abdominal pain Diaphragmatic defect secondary to remote MVA69 M Chest and abdominal pain and vomiting Diaphragmatic defect secondary to remote MVA57 M Chest and abdominal pain and vomiting Diaphragmatic defect secondary to remote MVA45 M Vomiting, abdominal pain and hematoemesis Diaphragmatic defect secondary to gunshot wound52 F Chest and abdominal pain and vomiting Hiatal hernia defect

MVA indicates motor vehicle accident.

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All patients underwent upper gastro-intestinal Bariumstudy preoperatively. Two of them underwent thoracic andabdominal CT as well. The radiological features of acutegastric volvulus demonstrated on these radiological studieswere reviewed and analyzed retrospectively by tworadiologists (H.A. and H.O.). These features includedpaucity of distal bowel gas, gastric air fluid level abovethe diaphragm, reversal of relative position of the greater tothe lesser curvatures of the stomach, and downwardpointing pylorus. Radiological features were correlatedwith operative findings.

Fig. 1. AP view of the stomach during upper gastrointestinal Barium studyshowing an upside down herniated distal stomach including antrum (A) intothe left hemithorax. The gastric fundus and proximal body (F) is normallylocated. The greater curvature of the stomach (curved arrow) is facingupward and is located above the level of lesser curvature. Notice thedownward pointing pylorus (arrowhead). Straight arrow is pointing to thegastro-esophageal junction.

3. Results

The patients' mean age was 50.4 years with age range of29–69 years. The patients included in the study were fourmen and one woman. Table 1 summarizes the clinicalfeatures of the study cases.

All patients presented with acute onset of epigastric painand recurrent vomiting. One of them reported history ofhematoemesis. Chest pain was a common complain.Patients' duration of symptoms to the time of surgery wasbetween 12 and 36 h.

Review of the upper gastro-intestinal Barium exams ofthe patients in this study showed organo-axial gastricvolvulus in all of them. The distal half of the stomach inthese patients herniated through a diaphragmatic defect orhiatal hernia and rotated by about 180 degrees around itslongitudinal axis. Secondary to this rotation, the greatercurvature of the gastric antrum and pylorus was locatedsuperior to the lesser curvature, a key feature of organ-axialvolvulus (Fig. 1). Both of these features were detected in allpatients. Barium studies in three of these patients demon-strated downward pointing pylorus, another radiologicalfeature of organ-axial volvulus (Fig. 2).

Lateral views obtained during Barium studies were veryhelpful in revealing the relationship of the distal stomachto its proximal part. In four patients, the distal abnormallyrotated gastric segment was located anterior to the fundusand gastric body (Fig. 3). In one patient, the distalsegment of the stomach was located posteriorly. Finding isprobably determined by the location of the underlyingdiaphragmatic defect.

CT scan was performed pre-operatively on two of ourpatients. Both CT scans showed the distal stomach herniatedthrough the left diaphragm. The abnormal rotation involvedonly the intra-thoracic portion of the stomach and the pyloruspassed through the same diaphragmatic defect back into theabdominal cavity (Fig. 4).

All patients underwent emergency laparoscopic surgerywith detorsion of the stomach, repair of the associateddiaphragmatic defect or hiatal hernia and gastric fixation.Operative findings in all patients revealed partial herniationof distal part of the stomach into the left hemithoraxassociated with almost 180° organ-axial rotation. In fourpatients, the stomach herniated through left traumaticdiaphragmatic defect resulting from either previous motorvehicle accident (n=3) or gunshot injury (n=1). In the fifth

Fig. 2. AP view the left upper abdomen and lower chest after administrationof Barium shows abnormally rotated distal stomach (A) had herniated intoleft hemithorax. The proximal gastric segment (F) is located below the leftdiaphragm. Arrowhead indicates the downward pointing pylorus.

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patient, the stomach was partially herniated through para-esophageal hiatal hernia defect (n=1).

Fig. 3. Upright lateral chest radiograph after administration of oral Barium.The gastric fundus (F) is normally located. The antrum (A) herniatedthrough diaphragmatic defect. Arrow indicates the distal marker of anasogastric tube failed to pass into the stomach. Downward pointing pylorusis indicated by arrowhead.

4. Discussion

Gastric volvulus is a relatively rare clinical entity thatinvolves abnormal acquired rotation of the stomach or part ofit [3]. The exact prevalence of this entity is unknown sincemany of these cases are chronic and can be asymptomatic.

Stomach is normally anchored by several ligaments inaddition to the gastroesophageal junction and pylorusallowing limited gastric movement. These ligaments includethe gastrocolic, gastrohepatic, gastrophrenic, and gastrsple-nic [4]. The etiology of gastric volvulus is unclear. Laxity ordisruption of these supporting gastric ligaments has beendescribed as a predisposing factor [5]. The presence of ahiatal hernia or a diaphragmatic defect facilitates itsdevelopment [1,6]. Several other clinical entities have beenreported to be associated with gastric volvulus such asdiaphragmatic eventration [7] or hernia [8], asplenia [9], andpost-surgical changes [6,10].

Organo-axial volvulus is the most common type [11]. Thestomach rotates around its longitudinal axis. This results inearly pyloric obstruction followed by obstruction at thegastroesophageal junction. This type is usually associatedwith either hiatal hernia or diaphragmatic defect. Most cases

of acute gastric volvulus are organo-axial [1]. This type isalso more likely to compromise gastric blood supplyresulting in gastric necrosis and gangrene.

Most mesenteroaxial gastric volvulus cases present witheither chronic or intermittent symptoms. The stomach rotatesaround its transverse axis. This type of volvulus tends to beidiopathic. Obstruction usually occurs at the mid-gastricbody. Strangulation with this type of volvulus is unusual.

Patients with acute gastric volvulus classically presentwith Borchardt's triad of severe epigastric pain anddistension, vomiting followed by retching, and difficulty inpassing the nasogastric tube into the stomach.

Upper gastrointestinal Barium study can confirm thisdiagnosis and determine its type. In organoaxial volvulus,Barium study shows greater curvature is superior to thelesser curvature and the pylorus is pointing inferiorly. If the

Fig. 4. Helical axial CT images of the lower chest and upper abdomen show the gastric fundus (F) is normally located in the upper abdomen and the gastricantrum (A) is located superiorly in left hemithorax. Arrow indicates the gastro-esophageal junction and the arrowhead indicates the gastric pylorus. Incidentallynoted is a calcified Hydatid cyst (H) in left liver lobe.

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pylorus is displaced superiorly and to the left and is seenoverlapping the gastroesophageal junction, mesenteroaxialgastric volvulus is the likely diagnosis [12].

CT scan can confirm the diagnosis of acute gastricvolvulus by revealing the abnormal herniation of the distalstomach into the left hemithorax and showing the reversedposition of the greater and lesser gastric curvatures. CT scancan also demonstrate associated predisposing findings likediaphragmatic defect. With advances in CT scan andimproved multi-planar reconstruction, CT is expected toplay a more important role in diagnosing this entity [8] asdemonstrated in this study and in multiple case reports andcase series in the literature [8,13,14].

The main limitation of our study is the small number ofcases include. This factor is related mostly to rarity of thisclinical entity since just over 300 cases have been reported inliterature so far [15].

5. Conclusion

In conclusion, upper gastrointestinal Barium study remainsan accurate and reliable modality in the diagnosis andcharacterization of acute gastric volvulus. CT scan ispotentially becoming of great diagnostic value in these cases.

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