Journal of Medical Imaging and Radiation Oncology  (2020) –

MEDICAL IMAGING—CASE OF THE MONTH

Adult mesentero-axial gastric volvulus: Case report

Journal of Medical Imaging and Radiation Oncology

Vijay Mistry, Erin Lee Gamble and Jennifer Chang
Princess Alexandra Hospital, Brisbane, Queensland, Australia

V Mistry MBBS (Hons); EL Gamble MD, Summary

J Chang BSc, MBBS, FRANZCR.
Correspondence
Dr Vijay Mistry, Department of Medical
Imaging, Princess Alexandra Hospital,
Woolloongabba, Qld 4102, Australia.
Email: vjmis3@gmail.com
Acute gastric volvulus is a rare surgical emergency which can lead to severe
complications such as gastric ischaemia and perforation. Gastric volvulus is
classified by the axis upon which the stomach rotates into organo-axial and
mesentero-axial subtypes, with the former more common in adults. We pre-
sent an uncommon case of recurrent adult mesentero-axial gastric volvulus
and describe the associated radiological findings.

Key words: CT; fluoroscopy; gastric volvulus; mesentero-axial.

Conflict of interest: The authors have no
conflict of interests to declare.

Submitted 18 November 2019; accepted 27

April 2020.

doi:10.1111/1754-9485.13051

mild leucocytosis with neutrophilia (white cell count

Introduction
Mesentero-axial gastric volvulus (MAGV) is an uncom-
mon1–3 subtype of gastric volvulus (GV) that can present
as a surgical emergency due to life-threatening compli-
cations. We present a case of recurrent adult MAGV and
describe the associated radiological findings that can
suggest this diagnosis in the acute setting and the imag-
ing features of potential complications.
Case report
A 58-year-old woman presented to the emergency
department with a 24-h history of gradual onset epigas-
tric pain, nausea and vomiting. Relevant background his-
tory included two prior episodes of MAGV that occurred 8
and 13 months prior to this presentation, which were
conservatively managed with nasogastric tube decom-
pression. The patient was on maintenance therapy for
the past 8 years for hormone receptor-positive meta-
static breast cancer with multiple stable subcentimetre
liver metastases. As part of her regular reviews, a
restaging CT performed serendipitously 3 days prior to
presentation demonstrated no evidence of GV and stable
metastatic disease. There was no prior history of
diaphragmatic abnormalities or hiatus hernia, and no
known history of phrenic nerve injury. Clinical examina-
tion demonstrated epigastric tenderness without radia-
tion. There was no guarding or peritonism. The patient
was afebrile, and initial bloods were only significant for a
12.1, neutrophils 10.1).
Erect chest X-ray demonstrated a double air-fluid level
(Fig. 1), and a nasogastric tube was subsequently
inserted without difficulty. Abdominal computed tomogra-
phy (CT) identified a MAGV with the pylorus located supe-
rior to the gastro-oesophageal junction (Fig. 2a–d). There
was no free intra-abdominal gas or pneumatosis. Fluo-
roscopy performed on the day of presentation (Fig. 3a,b)
confirmed MAGV and demonstrated delayed passage of
contrast through the gastroduodenal junction, which was
located superior to the gastro-oesophageal junction in
keeping with an incomplete gastric outlet obstruction
(Fig. 3c,d). The patient was admitted to the ward, and
after initial conservative management with nasogastric
decompression, their symptoms promptly resolved within
24 h. Approximately 72 h after presentation, the patient
underwent successful gastropexy. Intraoperative findings
identified a decompressed stomach with no features of GV
and did not identify any underlying anatomical abnormal-
ity of the diaphragm or laxity of the peritoneal ligaments.
The patient had not experienced any further episodes
three months after the gastropexy.
Discussion
Gastric volvulus is an uncommon condition occurring in
both adult3 and paediatric2,4 populations, with the lar-
gest case series in adults involving 36 patients over a
14-year period.3 Peak incidence has been reported in the

© 2020 The Royal Australian and New Zealand College of Radiologists 1

V Mistry et al.
Figure 1. Erect chest radiograph on presentation demonstrating a double
air-fluid level projected below the left hemidiaphragm.
fifth decade of life.1 GV is defined as the pathological
rotation of the stomach, classified by the axis upon which
the stomach rotates into mesentero-axial (Fig. 4a) and
organo-axial (Fig. 4b) subtypes, with a third combined
subtype involving rotation along both axes also
described.1,2 MAGV is less common compared with the
(a)
(c)
Figure 2. Axial (a, c) and coronal (b, d) CT images demonstrating diffuse gastric dilatation. The gastro-oesophageal junction (white arrow) is located inferior
to the pylorus and gastroduodenal junction (black arrow).
2 © 2020 The Royal Australian and New Zealand College of Radiologists
organo-axial subtype1–4 and is typically not associated
with predisposing anatomical or structural defects,
whereas the organo-axial subtype is typically secondary
to para-oesophageal hernias and diaphragmatic eventra-
tion. No clear underlying cause was identified in this
case. MAGV refers to rotation about the short axis of the
stomach leading to the anterior gastric wall folding upon
itself such that there is close approximation of the
pylorus and antrum to the gastro-oesophageal junction.
This close approximation has been proposed as the
cause of ischaemia as perfusion is dependent upon a sin-
gle vascular pedicle.4
The life-threatening complication of GV is formation of
a closed loop obstruction with strangulation which can
progress to gastric ischaemia and perforation. Prompt
diagnosis and management are crucial to minimise com-
plications, with mortality rates of 30–50%1 reported in
acute presentations. The classical acute clinical presenta-
tion of GV is described as Borchardt’s triad of severe
acute epigastric pain, vomiting followed by retching with
an inability to vomit, and difficult or inability to pass a
nasogastric tube, although in this case the patient was
able to have a nasogastric tube inserted without diffi-
culty. Presenting symptoms depend on the speed of
onset and severity of rotation and obstruction; however,
chronic presentations may not be recognised early due
to non-specific symptoms which can delay diagnosis.
Furthermore, nasogastric decompression prior to imag-
ing can inadvertently reduce the GV which may preclude
the imaging diagnosis in chronic presentations.
(b)
(d)
 Adult mesentero-axial gastric volvulus

General imaging findings of GV include air-filled retro- levels. Although findings are variable depending on the
cardiac mass on erect chest radiographs due to an point of torsion and degree of herniation, CT can assist in
intrathoracic stomach.1 Abdominal radiographs may iden- confirming the transition point. Complications of gastric
tify a distended, fluid-filled stomach with differential fluid ischaemia identifiable on CT include abnormal gastric

(a) (b)

(c) (d)

Figure 3. Fluoroscopy images demonstrating contrast passing through the gastro-oesophageal junction in the (a) erect and (b) supine positions. The gastro-
oesophageal junction (white arrow) is located inferior to the pylorus and gastroduodenal junction (black arrow). Initially, there was (c) no contrast transiting
through the gastroduodenal junction in the supine position; however after rotating the patient in the right lateral decubitus position, (d) contrast passage
into the duodenum was demonstrated.

Figure 4. (a) Mesentero-axial GV refers to rotation of the stomach along the short axis. (b) Organo-axial GV refers to rotation along the longitudinal axis.

© 2020 The Royal Australian and New Zealand College of Radiologists 3

V Mistry et al.
mucosal enhancement or pneumatosis, and free gas in
the setting of perforation.5 Fluoroscopy can assist in locat-
ing the pylorus relative to the gastro-oesophageal junc-
tion (Fig. 3a–d) and confirming the presence and degree
of obstruction. Rotation >180° can result in gastric outlet
obstruction (complete volvulus), identified on imaging as
retention of oral contrast material within the gastric
lumen; however, rotation in MAGV is typically <180°.
Based upon symptoms and degree of ischaemia, surgi-
cal reduction of the volvulus with repair of the predispos-
ing structural defects can be employed in the acute
setting; however, based on underlying patient comorbidi-
ties a more conservative approach may be taken.3 While
nasogastric decompression provided resolution of symp-
toms and allowed reduction of the GV in this case, a
decision was made for fixation of the stomach in an aim
to prevent recurrence.
In conclusion, we present an uncommon case of recur-
rent adult MAGV presenting with incomplete obstruction.
Given the severe potential complications associated with
delayed management, it is important for the reporting
radiologist to recognise and diagnose this condition par-
ticularly as presenting symptoms can create diagnostic
challenges.
4 © 2020 The Royal Australian and New Zealand College of Radiologists
Acknowledgement
Compliance with ethical standards: This research fol-
lowed the tenets of the 1964 Declaration of Helsinki and
its later amendments.
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