Mesenteroaxial volvulus in an adult: time is of the essence in acute presentation
Department of Medical Imaging, John Hunter Hospital, Newcastle, Australia
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
Keywords: Mesenteroaxial volvulus; paraoesophageal herniae
81 year-old female with known paraoesophageal herniae
presented with an acute episode of haematemesis and severe epigastric pain. The
patient had a background of hypertension, peptic ulcer disease and
gastro-oesophageal reflux disorder.
Gastroscopy was undertaken, confirming large
paraoesophageal herniae. A CXR showed large hiatus herniae (Figure 1). The
patient remained in the ward and deteriorated acutely. The herniae was thought
to be incarcerated and laparotomy with repair of paraoesophageal herniae was
planned. Unfortunately, the patient became unconscious, was unresponsive to
resuscitative efforts and passed away.
CT demonstrated complex hiatus hernia (Figure 2). The
antrum and part of the body of the stomach as well as proximal duodenum was
above the diaphragm. The oesophagus and fundus as well as the remaining part of
the body of the stomach was located below the diaphragm. The stomach was
markedly distended and the duodenum appeared to be compressed at the level of
the diaphragm by the stomach.
Acute gastric volvulus usually presents with Borchardt
triad of epigastric pain, retching without vomiting, and inability to pass
nasogastric tube (due to distortion of the anatomy at the gastroesophageal junction)
Gastric volvulus is defined as an abnormal rotation of the
stomach of more than 180 degrees, creating a closed loop obstruction. According
to the axis around which the stomach rotates it may either be organoaxial or
mesenteroaxial, or a combination of both .
Mesenteroaxial volvulus (which is the less common variant
- 29% of cases ) is where the stomach rotates around a transverse axis
connecting the middle of the greater and lesser curvatures. Gastric volvulus
can occur at any age, however, it is more common in children  with equal
frequency in both men and women .
Clinically, gastric volvulus can present as either an
acute abdominal emergency or as recurrent volvulus . 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 . Prompt recognition and decompression
are required to prevent infarction and perforation .
Traditionally acute gastric volvulus is diagnosed on a
chest X-ray showing retrocardiac air bubble or large air-fluid level in the
chest . A contrast study showing obstruction of the stomach at the site of
the volvulus confirms this diagnosis . However, a CT scan can offer an
immediate diagnosis with anatomical details. Coulier and Ramboux  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 .
Coulier and Ramboux further assert that the frequency of
this disease is probably underestimated because of the existence of partial
and/or spontaneously reversible forms .
In the case of paraoesophageal herniation, radiological
examination is again diagnostic. Films of the chest or abdomen may demonstrate
a high �stimulated� left diaphragm which is actually the herniated and
distended greater curvature of the stomach . 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 upper
quadrant or posteriorly . Massive gaseous distension in the upper abdomen or
chest may appear, with a gas bubble on either side of the midline . Barium
swallow studies demonstrate the classic signs of volvulus, such as sharp cut-off
of the oesophageal or gastric barium column, abnormal twisting of the rugal
folds, and finally delineation of the intrathoracic portion of the stomach .
The treatment is surgical consisting of laparotomy, de-rotation
and internal fixation .Gangrenous portions are resected. Recurrent volvulus
should be prevented by anterior gastropexy where the greater curvature of the
stomach is fixed to the anterior abdominal wall , and repair of the
diaphragmatic defect should be undertaken .
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)
Figure 5 Left sagittal image demonstrates an abrupt narrowing of the fluid-filled oesophagus at the level of the diaphragm. The nasogastric tube is demonstrated unable to pass into the stomach. (White arrowhead: oesophageal narrowing at diaphragm, White arrow: nas
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|Received 5 April 2009; received in revised form 3 June 2009,
accepted 4 June 2009
Correspondence: John Hunter Hospital, Lookout Rd, New Lambton, NSW Australia. E-mail: Please contact Managing Editor
Please cite as: Singham S, Sounness B,
Mesenteroaxial volvulus in an adult: time is of the essence in acute presentation, Biomed Imaging Interv J 2009; 5(3):e18