Radiological Category: Emergency Principal Modality (1): Principal Modality (2): Flouroscopy CT Case Report # [] Submitted by: Haider Virani, M.D. Faculty reviewer: Naga Chinapuvvula, MD Date accepted: 14 May 2015
Abdominal pain. Case History
Upper GI
Coronal CT
Test Your Diagnosis Which one of the following is your choice for the appropriate diagnosis? After your selection, go to next page. Normal stomach Organoaxial gastric volvulus Mesenteroaxial gastric volvulus Midgut volvulus with malrotation
Findings Findings: Upper GI exam Reversal 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 CT Shows similar findings as the upper GI examination.
Upper GI Nasogastric tube Antrum GEJ
Coronal CT Stomach Stomach 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.
What is your diagnosis? Normal stomach Organoaxial gastric volvulus Mesenteroaxial gastric volvulus Midgut volvulus with malrotation
Diagnosis Mesenteroaxial Gastric Volvulus
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 colorcoded 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). LC GC LC GC A GEJ A GEJ Normal stomach Organoaxial volvulus Normal stomach Mesenteroaxial volvulus
Organoaxial Gastric Position GC 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. LC
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. NGT GEJ A
Midgut Volvulus with Malrotation 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 midgut malrotation and in adults with midgut malrotation, the most common cause of bowel obstruction is midgut volvulus. With this entity, there is no rotation of the stomach as there is with gastric volvulus. The CT scanogram above shows gastric dilatation and a percutaneous gastrostomy tube.
Diagnosis Mesenteroaxial Gastric Volvulus Thank you for your attention!
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.