GV Mesenteroaxial

Available online at http://www.biij.
org/2009/3/e18
doi: 10.2349/biij.5.3.e18
biij
Biomedical Imaging and Intervention Journal
CASE REPORT
Mesenteroaxial volvulus in an adult: time is of the essence

in acute presentation
S Singham*, MBBS, LLB, B Sounness, MBBS
Department of Medical Imaging, John Hunter Hospital, Newcastle, Australia
Received 5 April 2009; received in revised form 3 June 2009, accepted 4 June 2009
ABSTRACT
Acute gastric volvulus is an uncommon condition with severe repercussions if untreated in the acute presentation.
We describe such a case. We assert that computed tomography (CT) should be the first line of investigation. © 2009
Biomedical Imaging and Intervention Journal. All rights reserved.
Keywords: Mesenteroaxial volvulus; paraoesophageal herniae
CASE REPORT the body of the stomach was located below the
diaphragm. The stomach was markedly distended and the
81 year-old female with known paraoesophageal duodenum appeared to be compressed at the level of the
herniae presented with an acute episode of haematemesis diaphragm by the stomach.
and severe epigastric pain. The patient had a background
of hypertension, peptic ulcer disease and gastro-
oesophageal reflux disorder. DISCUSSION
Gastroscopy was undertaken, confirming large
paraoesophageal herniae. A CXR showed large hiatus Acute gastric volvulus usually presents with
herniae (Figure 1). The patient remained in the ward and Borchardt triad of epigastric pain, retching without
deteriorated acutely. The herniae was thought to be vomiting, and inability to pass nasogastric tube (due to
incarcerated and laparotomy with repair of distortion of the anatomy at the gastroesophageal
paraoesophageal herniae was planned. Unfortunately, the junction) [1].
patient became unconscious, was unresponsive to Gastric volvulus is defined as an abnormal rotation
resuscitative efforts and passed away. of the stomach of more than 180 degrees, creating a
CT demonstrated complex hiatus hernia (Figure 2). closed loop obstruction. According to the axis around
The antrum and part of the body of the stomach as well which the stomach rotates it may either be organoaxial or
as proximal duodenum was above the diaphragm. The mesenteroaxial, or a combination of both [2].
oesophagus and fundus as well as the remaining part of Mesenteroaxial volvulus (which is the less common
variant - 29% of cases [3]) is where the stomach rotates
around a transverse axis connecting the middle of the
* Corresponding author. Present address: John Hunter Hospital, greater and lesser curvatures. Gastric volvulus can occur
Lookout Rd, New Lambton, NSW Australia. at any age, however, it is more common in children [4]
E-mail: (Please contact Managing Editor).
S Singham et al. Biomed Imaging Interv J 2009; 5(3):e18 2
This page number is not
for citation purposes
Figure 1 CXR demonstrates large hiatus herniae with air-fluid level projected over the heart. Nasogastric tube
can be seen at approximately T9 level.
Figure 2 Part of the body and antrum of the stomach are demonstrated above the diaphragm. The fundus is
located below the diaphragm. The duodenum is compressed against the diaphragm.
Figure 3 Coronal CT image demonstrates the duodenum compressed against the diaphragm. The distal body and
antrum are distended with fluid and superior to the diaphragm. (White arrow: duodenum, Fat white
arrow: diaphragm)
Figure 4 More anteriorly the duodenum is seen curling around the diaphragm and entering the abdomen via the
oesophageal hiatus. The proximal body and fundus are seen below the diaphragm. (White arrows:
duodenum, thick white arrow: diaphragm at the hiatus)
with equal frequency in both men and women [2].

Clinically, gastric volvulus can present as either an
acute abdominal emergency or as recurrent volvulus [5].
Intra abdominal gastric volvulus is usually associated
with contributing anatomic factors: abnormal stomach
mobility due to a lack of, or markedly lax ligaments,
gastric tumour, splenic or left hepatic lobe agenesis [6].
Prompt recognition and decompression are required to
prevent infarction and perforation [6].
Traditionally acute gastric volvulus is diagnosed on
a chest X-ray showing retrocardiac air bubble or large
air-fluid level in the chest [7]. A contrast study showing
obstruction of the stomach at the site of the volvulus
confirms this diagnosis [7]. However, a CT scan can
offer an immediate diagnosis with anatomical details.
Coulier and Ramboux [7] assert that helical CT should
be the first choice technique of imaging as it avoids any
delay in diagnosis. The CT and MR appearance may be
variable depending on the extent of gastric herniation
and the point of torsion of the stomach. In
mesenteroaxial volvulus, CT may show gastric
herniation of the antrum and distal body in the left
hemithorax, with inferior location of the
oesophagogastric junction below the diaphragm [8].
Coulier and Ramboux further assert that the
frequency of this disease is probably underestimated Figure 5 Left sagittal image demonstrates an abrupt narrowing
because of the existence of partial and/or spontaneously of the fluid-filled oesophagus at the level of the
diaphragm. The nasogastric tube is demonstrated
reversible forms [7]. unable to pass into the stomach. (White arrowhead:
In the case of paraoesophageal herniation, oesophageal narrowing at diaphragm, White arrow:
radiological examination is again diagnostic. Films of the nasogastric tube)
chest or abdomen may demonstrate a high “stimulated”
left diaphragm which is actually the herniated and
distended greater curvature of the stomach [9]. Double
air fluid levels occur if the fundic portion of the thoracic
stomach redescends into the abdomen. There may be a
“hairpin” loop with the incisura directed toward the right REFERENCES
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volvulus, such as sharp cut-off of the oesophageal or 3. Woon CY, Chung AY, Low AS et al. Delayed diagnosis of
gastric barium column, abnormal twisting of the rugal intermittent mesenteroaxial volvulus of the stomach by computed
tomography: a case report. J Med Case Reports 2008; 2:343.
folds, and finally delineation of the intrathoracic portion 4. Darani A, Mendoza-Sagaon M, Reinberg O. Gastric volvulus in
of the stomach [9]. children. J Pediatr Surg 2005; 40(5):855-8.
The treatment is surgical consisting of laparotomy, 5. Cybulsky I, Himal HS. Gastric volvulus within the foramen of
de-rotation and internal fixation [6].Gangrenous portions Morgagni. Can Med Assoc J 1985; 133(3):209-10.
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are resected. Recurrent volvulus should be prevented by palsy with kyphoscoliosis. Ulster Med J 2003; 72(2):118-20.
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stomach is fixed to the anterior abdominal wall [5], and diagnosed by helical CT. JBR-BTR 2002; 85(1):43.
repair of the diaphragmatic defect should be undertaken 8. Pelizzo G, Lembo MA, Franchella A et al. Gastric volvulus
associated with congenital diaphragmatic hernia, wandering spleen,
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Available online at http://www.biij.

Mesenteroaxial volvulus in an adult: time is of the essence

Keywords: Mesenteroaxial volvulus; paraoesophageal herniae

with equal frequency in both men and women [2].

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