eMedicine Specialties > Radiology > Gastrointestinal

Gastric Volvulus: Imaging

Author: Jeremy Green, MD, Attending Physician, Department of Radiology, New York Methodist Hospital
Coauthor(s): Marjorie Stein, MD, Clinical Assistant Professor of Radiology, Albert Einstein College of Medicine; Consulting Staff, Department of Radiology, Montefiore Medical Center
Contributor Information and Disclosures

Updated: Dec 22, 2008

Radiography


Supine abdominal image shows a mesenteroaxial vol...

Supine abdominal image shows a mesenteroaxial volvulus with a typical beak (arrow). Reprinted with permission from the American Journal of Roentgenology, to be used only in the eMedicine Radiology article Gastric Volvulus.

[ CLOSE WINDOW ]
Supine abdominal image shows a mesenteroaxial vol...

Supine abdominal image shows a mesenteroaxial volvulus with a typical beak (arrow). Reprinted with permission from the American Journal of Roentgenology, to be used only in the eMedicine Radiology article Gastric Volvulus.


Frontal chest image shows 2 air-fluid levels, 1 b...

Frontal chest image shows 2 air-fluid levels, 1 below the left hemidiaphragm and 1 retrocardiac, in a patient with paraesophageal hiatal hernia complicated by gastric volvulus. Reprinted with permission from the American Journal of Roentgenology, to be used only in the eMedicine Radiology article Gastric Volvulus.

[ CLOSE WINDOW ]
Frontal chest image shows 2 air-fluid levels, 1 b...

Frontal chest image shows 2 air-fluid levels, 1 below the left hemidiaphragm and 1 retrocardiac, in a patient with paraesophageal hiatal hernia complicated by gastric volvulus. Reprinted with permission from the American Journal of Roentgenology, to be used only in the eMedicine Radiology article Gastric Volvulus.


Findings

Mesenteroaxial volvulus

In mesenteroaxial volvulus, the distended stomach appears spherical on supine images. Two air-fluid levels are visible on the upright film: 1 in the fundus, which is inferior, and 1 in the antrum, which is superior. In addition, the upright image often demonstrates a beak where the esophagogastric junction is seen on normal images. If a nasogastric tube is passed, the esophagogastric junction is seen inferior to its normal location. If barium moves past the esophagogastric junction, the upside-down configuration of the stomach and the degree of obstruction can be documented.

Organoaxial volvulus

Organoaxial volvulus is difficult to diagnose on plain images. The stomach lies horizontally and contains a single air-fluid level on upright views. No characteristic beak is observed. Decreased air is noted within the remaining GI tract. Barium study shows that the esophagogastric junction is lower than normal. Marked gastric dilatation and the slow passage of contrast material past the site of twisting are noted.

Degree of Confidence

Plain radiographic findings that are suggestive of gastric volvulus should be confirmed with a barium study.

False Positives/Negatives

Although the classic plain radiographic findings described above are suggestive of volvulus, a false-negative diagnosis may result if the twisted stomach is filled with fluid. A distended, air-filled stomach may result secondary to other causes of gastric obstruction, leading to a false-positive diagnosis.

The barium study is highly sensitive and specific for gastric volvulus. It is generally considered to be the criterion standard for diagnosis. However, as stated above, the diagnosis may be missed in cases of intermittent torsion. The upper GI series may show only a paraesophageal hernia or eventration of the diaphragm during a symptom-free interval, leading to a false-negative diagnosis.

Computed Tomography

Findings

The computed tomography (CT) scanning and magnetic resonance imaging (MRI) appearance of gastric volvulus can be variable. The extent of diaphragmatic herniation, the points of torsion, and the final position of the stomach determine the appearance.6,7

Degree of Confidence

CT scanning and MRI are not typically considered to be the diagnostic examinations of choice in patients who are evaluated for gastric volvulus. However, some experts argue that the multiaxial reconstructions that are afforded by helical CT in particular may be preferred to the images obtained with conventional barium study, particularly in the acutely ill patient who is unable to tolerate a fluoroscopic examination. In addition, chronic gastric volvulus is often discovered incidentally in patients undergoing CT scanning for an unrelated condition. In most patients, CT-scan or MRI findings that suggest a gastric volvulus should be confirmed with an upper GI series.

False Positives/Negatives

Without torsion, gastric volvulus may be difficult to distinguish from paraesophageal hiatal hernia, and false-positive, as well as false-negative, diagnoses can result.

Ultrasonography

Findings

A study has demonstrated the peanut sign in a case of chronic gastric volvulus. The ultrasonographic features consist of a constricted segment of stomach, with 2 dilated segments located above and below the constricted part, akin to a peanut.8

Degree of Confidence

Ultrasonography is a noninvasive modality that can be performed on debilitated patients relatively easily and repeatedly; it requires no specific preparation. However, ultrasonography as a technique for the detection of gastric disease (and of gastric volvulus in particular) is still in its infancy. In several case reports, the ultrasonographic evaluation of gastric volvulus shows normal findings. Until more data are available, upper GI series should be used to confirm the diagnosis.

Nuclear Imaging

Findings

Gastric volvulus may be discovered during scintigraphic examination, sometimes incidentally, as the cause of a patient's symptoms. In 1 case report, a technetium-99m pertechnetate Meckel scan obtained to assess chronic GI bleeding in a child demonstrated an intrathoracic stomach with the greater curvature superior to the lesser curvature. Another case report demonstrated similar findings during an iodine-131 whole-body scan in a patient with metastatic thyroid cancer. In each case, upper GI series confirmed an organoaxial volvulus.

Degree of Confidence

Scintigraphic evidence of gastric volvulus should be confirmed with an upper GI series.

Angiography

Findings

During an episode of gastric volvulus, the arteries supplying the stomach are displaced according to the position of the stomach. Typically, the right and left gastroepiploic arteries are displaced high beneath the left hemidiaphragm. The right gastroduodenal artery also is displaced, and the left gastric artery appears to be coiled and shortened.

Degree of Confidence

Angiography is often used in the evaluation of massive or refractory GI hemorrhage. Although it is a rare cause of such hemorrhage, gastric volvulus should be considered. The angiographic appearance is sensitive and specific during an acute episode.

More on Gastric Volvulus

Overview: Gastric Volvulus
Imaging: Gastric Volvulus
Follow-up: Gastric Volvulus
Multimedia: Gastric Volvulus
References
Further Reading
[ CLOSE WINDOW ]

References

  1. Chau B, Dufel S. Gastric volvulus. Emerg Med J. Jun 2007;24(6):446-7. [Medline].

  2. Cribbs RK, Gow KW, Wulkan ML. Gastric volvulus in infants and children. Pediatrics. Sep 2008;122(3):e752-62. [Medline].

  3. Chattopadhyay A, Vepakomma D, Prakash B, et al. Is gastropexy required for all cases of gastric volvulus in children?. Int Surg. Jul-Aug 2005;90(3):151-4. [Medline].

  4. Gourgiotis S, Vougas V, Germanos S, et al. Acute gastric volvulus: diagnosis and management over 10 years. Dig Surg. 2006;23(3):169-72. [Medline].

  5. Oto A, Ernst RD, Ghulmiyyah LM, Nishino TK, Hughes D, Chaljub G, et al. MR imaging in the triage of pregnant patients with acute abdominal and pelvic pain. Abdom Imaging. Mar 11 2008;[Medline].

  6. Coulier B, Ramboux A, Maldague P. Intraabdominal counter clockwise gastric volvulus incarcerated through a defect of the lesser omentum: CT diagnosis. JBR-BTR. Nov-Dec 2007;90(6):519-23. [Medline].

  7. Coulier B, Broze B. Gastric volvulus through a Morgagni hernia: multidetector computed tomography diagnosis. Emerg Radiol. May 2008;15(3):197-201. [Medline].

  8. Braun U, Feller B, Hässig M, Nuss K. Ultrasonographic examination of the omasum, liver, and small and large intestines in cows with right displacement of the abomasum and abomasal volvulus. Am J Vet Res. Jun 2008;69(6):777-84. [Medline].

  9. Andiran F, Tanyel FC, Balkanci F, et al. Acute abdomen due to gastric volvulus: diagnostic value of a single plain radiograph. Pediatr Radiol. Nov 1995;25 Suppl 1:S240. [Medline].

  10. Brandt L. Gastrointestinal Disorders of the Elderly. New York, NY: Raven Press; 1984.

  11. Burke G, Mercado-Deane MG, Burton EM. Organoaxial gastric volvulus detected by Meckel scan. Clin Nucl Med. Jul 1994;19(7):598-9. [Medline].

  12. Campbell JB, Rappaport LN, Skerker LB. Acute mesentero-axial volvulus of the stomach. Radiology. Apr 1972;103(1):153-6. [Medline].

  13. Chiechi MV, Hamrick-Turner J, Abbitt PL. Gastric herniation and volvulus: CT and MR appearance. Gastrointest Radiol. Spring 1992;17(2):99-101. [Medline].

  14. Coulier B, Ramboux A. Acute obstructive gastric volvulus diagnosed by helical CT. JBR-BTR. 2002;85(1):43. [Medline].

  15. Fink DW. Gastric volvulus: the angiographic appearance. Am J Roentgenol Radium Ther Nucl Med. Jun 1972;115(2):268-70. [Medline].

  16. Godshall D, Mossallam U, Rosenbaum R. Gastric volvulus: case report and review of the literature. J Emerg Med. Sep-Oct 1999;17(5):837-40. [Medline].

  17. Gore RM, Levine MS, Laufer I. Textbook of Gastrointestinal Radiology. vol 1. Philadelphia, Pa: WB Saunders; 1994.

  18. Lim JH. Ultrasound examination of gastrointestinal tract diseases. J Korean Med Sci. Aug 2000;15(4):371-9. [Medline].

  19. Marshak R, Lindner A, Maklansky D. Radiology of the Stomach. Philadelphia, Pa: WB Saunders; 1983.

  20. Matsuzaki Y, Asai M, Okura T, et al. Ultrasonography of gastric volvulus: "peanut sign". Intern Med. Jan 2001;40(1):23-7. [Medline]. [Full Text].

  21. Menuck L. Plain film findings of gastric volvulus herniating into the chest. AJR Am J Roentgenol. Jun 1976;126(6):1169-74. [Medline].

  22. Meschan I. Roentgen Signs in Diagnostic Imaging. vol 1. Philadelphia, Pa: WB Saunders; 1984.

  23. Milne LW, Hunter JJ, Anshus JS, et al. Gastric volvulus: two cases and a review of the literature. J Emerg Med. 1994;12:299-306. [Medline].

  24. Schaefer DC, Nikoomenesh P, Moore C. Gastric volvulus: an old disease process with some new twists. Gastroenterologist. Mar 1997;5(1):41-5. [Medline].

  25. Sleisinger MH, Fortran JS. Gastrointestinal Disease: Pathophysiology, Diagnosis, and Management. Philadelphia, Pa: WB Saunders; 1973.

  26. Wasselle JA, Norman J. Acute gastric volvulus: pathogenesis, diagnosis, and treatment. Am J Gastroenterol. Oct 1993;88(10):1780-4. [Medline].

  27. Ziprkowski MN, Teele RL. Gastric volvulus in childhood. AJR Am J Roentgenol. Jun 1979;132(6):921-5. [Medline].

  28. Zollikofer CL, Jost R, Schoch E, et al. Gastrointestinal stenting. Eur Radiol. 2000;10(2):329-41. [Medline].

  29. Zucker RJ, Bradley YC, Toney MO, et al. Gastric volvulus detected with iodine-131 whole-body imaging. Clin Nucl Med. Apr 2000;25(4):303-5. [Medline].

[ CLOSE WINDOW ]

Keywords

gastric volvulus, gastric torsion, closed-loop obstruction, gastric strangulation, gastric rotation, subdiaphragmatic volvulus, primary volvulus, supradiaphragmatic volvulus, mesenteroaxial volvulus, secondary volvulus

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Jeremy Green, MD, Attending Physician, Department of Radiology, New York Methodist Hospital
Jeremy Green, MD is a member of the following medical societies: American College of Radiology
Disclosure: Nothing to disclose.

Coauthor(s)

Marjorie Stein, MD, Clinical Assistant Professor of Radiology, Albert Einstein College of Medicine; Consulting Staff, Department of Radiology, Montefiore Medical Center
Marjorie Stein, MD is a member of the following medical societies: American College of Radiology, American Institute of Ultrasound in Medicine, and Radiological Society of North America
Disclosure: Nothing to disclose.

Medical Editor

Neela Lamki, MD, Professor, Department of Radiology, Sultan Qaboos University, Oman; Adjunct Professor, Department of Radiology, Baylor College of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

Abraham H Dachman, MD, FACR, Professor, Department of Radiology, The University of Chicago School of Medicine; Director of CT, Department of Radiology, The University of Chicago Hospitals
Abraham H Dachman, MD, FACR is a member of the following medical societies: Radiological Society of North America
Disclosure: iCAD, Inc. Consulting fee Consulting; iCAD, Inc. Grant/research funds Other; GE Healtcare, Inc. Honoraria Speaking and teaching

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Eugene C Lin, MD, Consulting Radiologist, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology, University of Washington School of Medicine
Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, and Society of Nuclear Medicine
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.