Click below to learn more about the case.
Findings in this case: 1) Mesenteric fat is seen to extend from the RIGHT upper quadrant into the chest. 2) There is a small amount of fluid present posteriorly within the mediastinum. 3) A nasogastric tube is present within the esophagus and a small of gastric fundus. There is contrast material within the esophagus and in this small segment of gastric fundus. No contrast material extends beyond a very narrowed segment. 4) The stomach is markedly distended with an air-fluid level present. 5) There are loops of intestine within the area posterior to the stomach and in the posterior mediastinum. When this is followed, this represents the transverse colon which has been rotated into the mediastinum with the mesenteric fat. 6) The antrum, the smaller of the 2 segments of the stomach which are dilated, lies to the LEFT of midline and can be seen to connect to the duodenum which is to the RIGHT of midline in normal position. 7) The larger of the areas of gastric dilatation lying centrally, inferiorly and to the RIGHT of midline represents most of the body of the stomach and fundus. Only a small amount of fundus is seen with the contrast material present as noted above.
Diagnosis: Gastric Volvulus.
File: 3C
Organ system: 3. Gastrointestinal tract.
Organ: C. Stomach.
Etiology and incidence: 1) Gastric volvulus is a closed loop obstruction which occurs when there is a rotation of the stomach of greater than 180 degrees. 2) There are 2 axes of rotation: a) Between the gastroesophageal junction and the pylorus or the rotation is vertical/RIGHT-LEFT – organoaxial; b) The most common type representing approximately 60% of cases; c) Horizontal in relation to the stomach where the rotation is superior/inferior along this axis – mesenteroaxial. This is the second most common type, is seen at approximately 30% of cases; d) A third type of gastric volvulus is a combination of organoaxial and Mesenteroaxial.
Prevalence: 1) Bimodal age distribution with up to 20% of cases in children, more adequately mesenteroaxial, with the second age distribution at greater than 50 to 60 years. 2) Male to female ratio is 1:1.
There is a secondary classification based on etiology: 1) Type 1: Idiopathic. Approximately 2/3 of cases; a) Most common in adults; b)Abnormal laxity in the gastric ligaments. 2) Type 2: Congenital/acquired. Approximately 1/3 of cases; a) More frequently seen in children; b)In the article from Miller et al., 85% of cases were related to congenital defects in the diaphragm or gastric ligaments. 3) Associated abnormalities predisposing to gastric volvulus include: Paraesophageal hiatal hernia, other congenital/acquired diaphragmatic defects, surgery (liver transplant, fundoplication, vagotomy, gastric band), neuromuscular disorders, tumors and congenital abnormalities of the gastric/abdominal ligaments.
Diagnosis: 1) Clinical triad inability to pass a nasogastric tube, severe epigastric pain and retching without vomiting. 2) Types of gastric volvulus; a) Organoaxial: The stomach rotates around the axis formed between the gastroesophageal junction in the pylorus, The antrum rotates in a direction opposite to the fundus, and usually seen in relation with a hiatal hernia; b) Mesenteroaxial: The rotation of the stomach brings the posterior surface of the stomach anteriorly with the antrum remaining in relation to the body of the stomach and not inverse as is seen with organoaxial rotation, The rotation may be incomplete. Vascular compromise is based on the completeness of the rotation and any organoaxial component. Frequently not seen in relation to a hiatal hernia; c) Combined: Rotation on both the organoaxial and Mesenteroaxial axes.
Prognosis/Clinical; 1) Organoaxial volvulus, the most common type, is associated with gastric necrosis secondary to loss of vascular supply and 25 to 30% of cases; 2) Mesenteroaxial volvulus and is more frequently chronic and incomplete therefore, vascular compromise and gastric ischemia is seen much less commonly; 3) Delays and diagnosis of gastric volvulus lead to gastric ischemia, perforation and a high rate of mortality; 4) Nonoperative mortality has been reported at greater than 80%. With appropriate treatment, the mortality rate is reduced to 15 to 20% for acute volvulus and up to 13% for chronic volvulus.
It should be noted that cases of paraesophageal hiatal hernia and large hiatal hernias with a significant amount of stomach extending into the mediastinum are treated surgically in many cases as these are associated with acute or chronic volvulus. It is important to diagnosis and note these abnormalities when they occur on CT, plain films or upper GI series.
Reference: Continuing Medical Education: Complications of Congenital and Developmental Abnormalities of the Gastrointestinal Tract in Adolescents and Adults: Evaluation with Multimodality Imaging
Nam Kyung Lee, Suk Kim, Tae Yong Jeon, Hyun Sung Kim, Dae Hwan Kim, Hyung Il Seo, Do Youn Park, and Ho Jin Jang
Radiographics October 2010 30:1489-1507; doi:10.1148/rg.306105504
Gastric Volvulus; William W Hope, MD et al. http://emedicine.medscape.com/article/190750-overview
Gastric volvulus in the pediatric population. Miller DL, Pasquale MD, Seneca RP, Hodin E. Arch Surg. 1991 Sep;126(9):1146-9.
Acute gastric volvulus: case report and review of the literature
Case Reports
William E. Sevcik, MD;* Ivan P. Steiner, MD†
CJEM 1999;1(3):200-203http://www.cjem-online.ca/v1/n3/p200
Gastric Volvulus Imaging
Author: Jeremy Green, MD; http://emedicine.medscape.com/article/368732-overview#a01
