Case Report # []

Submitted by: Haider Virani, M.D.

Faculty reviewer: Naga Chinapuvvula, MD

Date accepted: 14 May 2015

Radiological Category: Principal Modality (1):

Principal Modality (2):

Emergency

CT

Flouroscopy

Case History

Abdominal pain.

Upper GI

Coronal CT

• Normal stomach

• Organoaxial gastric volvulus

• Mesenteroaxial gastric volvulus

• Midgut volvulus with malrotation

Which one of the following is your choice for the appropriate diagnosis? After your selection, go to next page.

Test Your Diagnosis

Upper GI examReversal of the position of the gastroesophageal junction (GEJ) and antrum of the stomach. The orientation of the lesser and greater curvatures of stomach with respect to each other are preserved.

Coronal CTShows similar findings as the upper GI examination.

Findings:

Findings

Upper GI

Nasogastric tube

Antrum

GEJ

Coronal CT

These coronal CT images of the abdomen of the same patient as in the previous slide demonstrate twisting of the stomach about its short axis that results in a superior position of the gastric antrum relative to the gastroesophageal junction. The nasogastric tube is seen to course inferior to the gastric antrum.

Stomach

Stomach

• Normal stomach

• Organoaxial gastric volvulus

• Mesenteroaxial gastric volvulus

• Midgut volvulus with malrotation

What is your diagnosis?

Mesenteroaxial Gastric Volvulus

Diagnosis

Normal Anatomy

Upper GI examination (left) showing a normal stomach and an axial non-contrast CT scan (right) showing predominantly the liver and stomach. Lesser and upper curvatures of the stomach are color-coded on both images. In the upper GI examination, the fundus is filled with contrast. In the axial CT scan, the position of the gastrohepatic ligment (in yellow above) is also demonstrated.

Gastric Volvulus

Gastric volvulus occurs when there is a laxity of the gastric ligaments and an anatomic environment that allows for gastric mobility such as paraesophageal hernia, post-traumatic diaphragmatic hernia, left hemidiaphragmatic paralysis, and diaphragmatic eventration.

There are two types of gastric volvulus – organoaxial and mesenteroaxial. Organoaxial gastric volvulus is the most common type and occurs when the greater curvature (GC) of the stomach is superior to the lesser curvature (LC) due to rotation along the long axis of the stomach. Mesenteroaxial gastric volvulus occurs when there is rotation around the short axis of the stomach (or gastrohepatic ligament) that positions the gastric antrum (A) superior to the gastroesophageal junction (GEJ).

GEJ

A GEJ

A

GC

GC

LCLC

Organoaxial volvulus

Mesenteroaxial volvulus

Normal stomach Normal stomach

Organoaxial Gastric Position

GC

LC

This upper GI examination demonstrates reversal of the greater (GC) and lesser curvatures (LC) of stomach, however, there is no obstruction and the term organoaxial position of the stomach is preferred. This gastric orientation does predispose to obstruction and if gastric distention is also observed then a diagnosis of organoaxial gastric volvulus is appropriate.

Mesenteroaxial Gastric Volvulus

This upper GI examination demonstrates reversal of the gastroesophageal junction (GEJ) and antrum (A) of the stomach. The position of the GEJ is corroborated by the nasogastric tube (NGT). Note that the orientation of the lesser and greater curvatures of the stomach with respect to each other are preserved. The degree of rotation is typically less than 180 degrees and this type of volvulus is usually not associated with a diaphragmatic abnormality.

NGTA

GEJ

Midgut Volvulus with Malrotation

The CT scanogram above shows gastric dilatation and a percutaneous gastrostomy tube.

Midgut volvulus occurs in the setting of bowel malrotation. Normally, the small bowel mesenteric attachment to the posterior abdominal wall runs from the ligament of Treitz to the cecum. However when this mesenteric attachment to the posterior abdominal wall is shortened, most of the proximal small bowel is situated in the right abdomen as the duodenum fails to cross midline towards expected the location of the ligament of Treitz. This configuration is referred to as midgutmalrotation and in adults with midgutmalrotation, the most common cause of bowel obstruction is midgutvolvulus.

With this entity, there is no rotation of the stomach as there is with gastric volvulus.

Mesenteroaxial Gastric Volvulus

Thank you for your attention!

Diagnosis

References

1. Delabrousse E, Sarliève P, Sailley N, Aubry S, Kastler BA. Cecal volvulus: CT findings and correlation with pathophysiology. Emerg Radiol. 2007 Nov;14(6):411-5.

2. Peterson CM, Anderson JS, Hara AK, Carenza JW, Menias CO. Volvulus of the gastrointestinal tract: appearances at multimodality imaging. Radiographics. 2009 Sep-Oct;29(5):1281-93.

3. Ayoob AR, Lee JT. Imaging of Common Solid Organ and Bowel Torsion in the Emergency Department. AJR 2014; 203:W470–W481.

4. Bernstein SM, Russ PD. MidgutVolvulus: A Rare Cause of Acute Abdomen in an Adult Patient. AJR 1998;171:639-641.

5. Ortiz-Neira CL. The corkscrew sign: midgut volvulus. Radiology. 2007 Jan;242(1):315-6.