Eur Radiol
DOI 10.1007/s00330-014-3319-2
GASTROINTESTINAL
Computed tomography findings of acute gastric volvulus
Ingrid Millet & Celine Orliac & Chakib Alili &
Françoise Guillon & Patrice Taourel
Received: 27 November 2013 / Revised: 17 June 2014 / Accepted: 7 July 2014
# European Society of Radiology 2014
Abstract
Purpose To assess the diagnostic performance of CT signs of
gastric volvulus in both confirmed cases and control subjects.
Materials and methods We retrospectively reviewed CT find-
ings in 10 patients with surgically confirmed acute gastric
volvulus and 20 control subjects with gastric distension.
Two radiologists independently evaluated CT images for risk
factors of gastric volvulus, direct findings of gastric volvulus
by assessing gastric dilatation, the presence of an antropyloric
transition point, the respective position of the different stom-
ach segments and of the greater and lesser curvatures, stenosis
of the gastric segments through the oesophageal hiatus and for
findings of gastric ischemia. The sensitivity and specificity of
each finding were calculated.
Results The most sensitive direct signs of gastric volvulus
were an antropyloric transition point without any abnormality
at the transition zone and the antrum at the same level or
higher than the fundus. The presence of both these two find-
ings as diagnostic criteria of gastric volvulus had 100 %
sensitivity and specificity for the diagnosis of gastric volvulus.
There was no association between CT signs of ischemia and
final bowel ischemia at pathology.
Conclusion CT is both highly sensitive and specific for diag-
nosing acute gastric volvulus.
Key Points
• CT is highly reliable for diagnosing acute gastric volvulus
with two findings.
• The two signs are gastropyloric transition zone and abnor-
mal location of the antrum.
• This allows fast surgical management of this emergency.
I. Millet : C. Orliac : C. Alili : P. Taourel (*)
Department of Radiology, Hopital Lapeyronie, Montpellier, France
e-mail: p-taourel@chu-montpellier.fr
F. Guillon
Department of Surgery, University Hospital of Montpellier,
Montpellier, France
Keywords Bowel obstruction . Stomach . Volvulus .
Computed tomography
Introduction
Gastric volvulus is defined as an abnormal rotation of the
stomach with three categories characterized according to their
axes of rotation [1–3]. Organoaxial volvulus, the most com-
mon cause, occurs when the stomach rotates along its long
axis, resulting in an inverted stomach lying on the horizontal
plane. It is associated with paraoesophageal hernia and dia-
phragmatic hernia. Mesenteroaxial volvulus occurs when the
stomach rotates along its short axis. In this position the stom-
ach lies in the vertical plane, with displacement of the antrum
rotated above the gastroesophageal junction. The third and
rarest form of gastric volvulus associates rotation in both the
organoaxial and mesenteroaxial axes.
Regardless of its form, acute gastric volvulus repre-
sents an acute life-threatening surgical emergency be-
cause of its risk of gastric ischemia, necrosis and per-
foration. Although acute gastric volvulus is considered as
very rare, the exact prevalence of gastric volvulus is unknown
since many cases may be chronic or may spontaneously
resolve even if acute.
Historically, gastric volvulus has been diagnosed using
conventional radiography. Barium studies clearly show the
relationship between the different stomach segments [4–6].
Although upper gastrointestinal barium studies are highly
sensitive for gastric volvulus [6–8], they are not currently
performed in patients with gastric volvulus because this diag-
nosis is seldom clinically suspected. By contrast, in clinical
practice, patients presenting with acute abdominal symptoms
usually undergo computed tomography (CT). A pictorial
essay [1] has described the appearance of volvulus of
the gastrointestinal tract in various localizations with CT
which helps to confirm the rotation of the herniated stomach

and the transition point in gastric volvulus. Several case
reports [9–14] have described the CT features of gastric
volvulus and its associated conditions, such as diaphrag-
matic defects and wandering spleen [12]. Published CT
signs of gastric volvulus include a transition point at the
pylorus, herniation of the antrum into the left hemithorax,
antropyloric junction above the gastroesophageal junction,
reversed position of the greater and lesser gastric curvatures,
stenosis of the gastric segments through the stretched
oesophageal hiatus, clearly seen on the coronal recon-
struction. To our knowledge, there have been no studies
to date describing the sensitivity and specificity of these
different CT findings of gastric volvulus. The purpose
of this study was to assess the diagnostic performance
of CT signs of gastric volvulus in both confirmed cases and
control subjects.
Materials and methods
Patient population
This retrospective study was approved by the institutional
review board and compliant with the Health Insurance
Portability and Accountability Act. The informed consent
requirement was waived. By analysing our institutional sys-
tem database, we retrospectively identified consecutive pa-
tients who had been assigned the diagnostic code for acute
gastric volvulus from January 2007 to May 2013. The records
of 25 clinical cases were obtained and revealed 15 patients
with a diagnosis of gastric volvulus confirmed by surgery.
Eleven of these patients underwent CT before the treatment
intervention and had original image sets available for retro-
spective analysis. One patient was excluded because the time
interval between the onset of the symptoms and the CT exam
was over a week. Our gastric volvulus study population thus
included 10 patients. For these patients, the interval between
the onset of acute symptoms and CT ranged from 5 to 72 h
(median, 10), while the interval between CT and surgery
ranged from 4 to 72 h (median, 8).
We identified the control population by searching in our
CT information system report database for cases of CT with
findings of gastric or gastroduodenal distension without small
bowel dilatation investigated between January 2007 and May
2013. Among these patients, 34 received a final diagnosis
other than gastric volvulus. We randomly chose 20 of these
34 patients to constitute the control group and thus obtained a
case/control ratio of 1:2. The final diagnosis was established
by surgery in two cases, endoscopy in five cases and
follow-up in 13 cases, and included idiopathic gastric
distention (n=13), incarcerated hiatal hernia (n=2) treated
by surgery in two cases, duodenal peptic ulcer (n=1) and
tumoral obstruction (n=4).
Eur Radiol
Clinical data
Medical charts were reviewed for demographic data, present-
ing symptoms, endoscopic, surgical and pathological results,
final diagnosis and clinical outcome. Pathologic and surgical
reports were reviewed for the following descriptors of bowel
compromise: ischemia, haemorrhage and perforation.
CT technique
CT was performed using a LightSpeed VCT 64-detector row
scanner (GE Healthcare, Milwaukee, Wis). CT scanning was
performed at 120 kVp, and the amperage setting ranged from
130 to 700 mA, according to the body habitus. The CT
images were reconstructed at 3-mm section thickness in
the axial plane, with native images available for interpreta-
tion. Coronal and sagittal reconstructions were performed at
the time of clinical imaging in all patients using a 3-mm
section thickness with 1.5-mm overlap. Eight of the 10 studies
in the patients with gastric volvulus and 13 of the 20 control
studies were performed during the portal venous phase (delay
of 70–80 s) with intravenous contrast material: iohexol
(Omnipaque 300; GE Healthcare) or iobitridol (Xénétix 350;
Guerbet) administered via a power injector at 2–3 mL/s,
whereas two patients of the volvulus group and seven of the
control group did not have enhanced CT because of renal
failure.
No patients in our study had undergone barium examination.
Image analysis
Two attending radiologists (I.M., C.A.) with extensive expe-
rience in emergency imaging (8 and 5 years, respectively) and
subspecialty training in abdominal or gastrointestinal radiolo-
gy independently reviewed all gastric volvulus and control
cases in random order on a dedicated PACS unit (GE
Healthcare). The reviewers were blinded to the final diagnosis
but were aware that they were involved in a research study
about gastric volvulus. For analysis, native axial images and
reconstructed axial coronal and sagittal images at 3-mm sec-
tion thickness were available. Inter-reviewer disagreements
were resolved by consensus among the two readers.
The CT images were examined for the following: 1.
Contributing factors associated with gastric volvulus: (a)
paraoesophageal hernia, (b) other diaphragmatic hernia, (c)
left hepatic lobe agenesis, (d) wandering spleen; 2. Direct
findings of gastric volvulus: (a) severe gastric dilatation
evaluated by measurement of the anteroposterior diame-
ter of the stomach greater than 10 cm, (b) identification of an
antropyloric transition point which was analysed for the pres-
ence of a mass or thickening of the bowel wall at the transition
point, (c) intrathoracic position of the fundus, (d) intrathoracic
position of the body of the stomach, (e) intrathoracic position
Eur Radiol

of the antrum, (f) reversed position of the greater and lesser
curvature of the stomach, which was identified if the right
side of the oesophagus was not in continuum with the
lesser curvature but was with the greater one, (g) an-
trum in abnormal high location at the same level or
higher than the fundus, (h) stenosis of the gastric seg-
ments through the stretched oesophageal hiatus, (i)
perigastric intraperitoneal fluid which was considered
as the consequence of venous system strangulation and; 3.
Findings of gastric ischemia: (a) gastric wall pneumatosis, (b)
lack of gastric wall enhancement, (c) pneumoperitoneum,
retroperitoneum or pneumomediastinum, and (d) findings of
hepatic, splenic or pancreatic ischemia.
Statistical analyses
0.61–0.8, substantial agreement; and κ=0.81–1, almost
perfect agreement [15].
In order to identify a subpopulation containing all patients
for whom acute gastric volvulus was detected, we looked for a
predictive classification rule with 100 % sensitivity for the
prediction of a positive CT screening for acute gastric volvu-
lus. Among the perfect sensitivity models, we chose one with
optimal specificity.
Univariate logistic regression was used to evaluate the
association between the CT findings of ischemia and bowel
ischemia at the pathology analysis.
Statistical significance for all tests was set at a p value of
less than 0.05. SAS software, version 9.3 (SAS Institute Cary,
NC) was used to perform the statistical analyses.

Baseline statistical values for the gastric volvulus and control
groups were analysed using a two-tailed chi-square or Fisher
test, as appropriate, to compare proportions. The sensitivity
and specificity of each contributing factor and direct signs
were calculated.
Interobserver agreement for all the evaluated CT
findings was determined with the κ statistic and classi-
fied as follows: κ=0–0.2, slight agreement; κ=0.21–0.4,
fair agreement; κ= 0.41–0.6, moderate agreement; κ =
Results
Study population
The group of 10 patients in whom gastric volvulus was
diagnosed consisted of two men and eight women, with an
age range of 74–87 years (median, 83 years). The control
group of 20 patients consisted of 11 men and nine women
with an age range of 52–85 years (median, 72.5 years).

Table 1 Diagnostic performance and interobserver agreement for CT signs of gastric volvulus

Signs Volvulus Control p value Sensitivity Specificity Interobserver

group group agreement

(n=10) (n=20) % 95 % CI % 95 % CI Kappa 95 % CI

Contributing factors
Paraoesophageal hernia 8 2 2.9×10−4 80 [44–97] 90 [68–98] 0.85 [0.64–1]
Other diaphragmatic hernia 1 0 0.33 10 [0–44] 100 1
Wandering spleena 0 0 1 0 100 1
Agenesis of the left liver 1 4 0.64 10 [0–44] 80 [56–94] 1
Direct findings
Severe gastric distension >10 cm 2 9 0.24 20 [2–55] 55 [31–76] NA NA
AP transition point 10 5 0.0001 100 75 [50–91] 0.85 [0.65–1]
AP transition point without mass 10 2 2.2×10−6 100 90 [68–98] 0.85 [0.65–1]
Antrum at the same level or higher than the fundus 10 1 3.6×10−7 100 95 0.79 [0.58–1]
Intrathoracic position of the fundus 5 1 0.008 50 [18–81] 95 [75–99] 0.88 [0.67–1]
Intrathoracic position of the body 2 1 0.25 20 [2–55] 95 [75–99] 0.51 [0.04–0.99]
Intrathoracic position of the antrum 9 1 6.6×10−6 90 [55–99] 95 [75–99] 1
Stenosis of the gastric segments through the stretched 3 1 0.09 33 [7–70] 50 [1–98] 0.51 [0.04–0.99]
oesophageal hiatusb
Whirl sign 0 0 1 0 100 1
Reversed position of the greater and lesser curvature 3 0 0.03 30 [6–65] 100 0.36 [0.04–0.68]
Perigastric intraperitoneal fluid 3 2 1 20 [2–55] 85 [62–97] 1
a
Splenectomy in one patient
b
Only 11/30 patients had a paraoesophageal or other diaphragmatic hernia, so this CT sign was evaluable in only 11 patients
 Eur Radiol

There was no statistically significant difference in the

sex or age distribution in the two groups (p=0.11 and p=
0.12, respectively).
In the volvulus group, abdominal pain, vomiting, upper
gastrointestinal bleeding and respiratory symptoms were pres-
ent in six, nine, two and two patients, respectively. In the
control group, abdominal pain, vomiting, upper gastrointesti-
nal bleeding and respiratory symptoms were present in 13, 13,
two and six patients, respectively.
Gastric ischemia was detected at surgery in 2 patients with
volvulus, whereas ischemia was not present in any of the
control subjects.
Among the 10 patients with gastric volvulus, two died
while in the hospital, including one of the two patients with
gastric ischemia at surgery. Among the 20 patients of the
control group, four died while in the hospital, including two
patients with a non-obstructive acute gastric dilatation, one
patient with a pancreas cancer and one patient with a duodenal
stenosis complicating a paraoesophageal hernia without vol-
vulus. No cases of death in the control group were related to
gastric ischemia. Apart from the two patients who died during
hospitalization, the patients with a non-obstructive acute gas-
tric dilatation had regression of their symptoms during
hospitalization.

CT findings of volvulus

The frequencies of predisposing and diagnostic factors in

gastric volvulus and control groups are shown in Table 1.
A paraoesophageal hernia was present in eight of the 10
patients (80 %) with gastric volvulus (Fig. 1) and in two of the
20 control subjects (10 %), with a significant difference
(p=2.91×10−4). There was no significant difference in the
other evaluated contributing factors: a post-traumatic dia-
phragmatic hernia was present in one patient with gastric
volvulus (10 %), a left hepatic lobe agenesis was encountered
in one patient of the volvulus group (10 %), whereas a wan-
dering spleen was never present in this group.
A severe gastric distension was present in two of the
patients with volvulus and in 11 patients of the control
group. An antropyloric transition point was encountered
in all patients with volvulus and in five patients of the
control group (5/20, 25 %) including three antropyloric
cancers, one peptic ulcer pylorus stenosis (Fig. 2) and
one non-obstructive acute gastric dilatation. In the three
cancer cases, thickening of the antropyloric bowel wall
was present.
The antrum was in an intrathoracic position in all patients
with volvulus except one and was never located lower than the
fundus; it was above the fundus in five patients (Fig. 3) and at
the same level in five patients (Fig. 4). In the control group, the
antrum was intrathoracic in one patient who had a
paraoesophageal hernia with gastric obstruction due to
Fig. 1 94-year-old man with surgically confirmed gastric volvulus. a
Coronal reconstruction shows stenosis of the stomach (arrow) between
the body (B) and the herniated antrum (A) through the stretched oesopha-
geal hiatus. b Sagittal reconstruction shows the antropyloric transition point
(arrowhead) without mass or thickening of the gastric wall just below the
antrum (A). The body (B) of the stomach is lower than the antrum
incarceration of the duodenum and was located at the same
level as the fundus in one patient and never above. In the
patients presenting with a hiatal hernia, stenosis of the gastric
segments through the stretched oesophageal hiatus was en-
countered in three patients (33 %) of the volvulus group and in
one patient (1/2 50 %) of the control group. A reversed
position of the greater and lesser curvature of the stomach
was encountered in three patients (30 %) with gastric volvulus
and in no patients of the control group.
The calculated diagnostic performance values and the
kappa values for all predisposing and diagnostic CT
signs are listed in Table 1. All the significant CT findings
of acute gastric volvulus were reproducible, with kappa
statistics ranging from 0.79 to 1, except for the reversed
position of the greater and lesser curvature with a slight
kappa (0.36).
Eur Radiol
Fig. 2 37-year-old man with peptic ulcer stenosis of the pylorus con-
firmed by endoscopy and biopsy. a Coronal reconstruction shows steno-
sis of the pylorus (arrow) with thickening of the pylorus wall. b Axial
slice more clearly shows the thickening of the pylorus wall (arrow)
The best diagnostic combination was the presence of
both an antropyloric transition point without any abnor-
mality at the transition zone and an abnormally located
antrum at the same level or higher than the fundus, with
100 % sensitivity and specificity for CT diagnosis of gastric
volvulus.
CT findings of ischemia
There was no relationship between CT signs of ischemia and
final bowel ischemia at pathology (Table 2). CT findings of
ischemia were present in two patients with gastric volvulus
with a true positive, a false positive and a false negative, and in
five patients of the control group with gastric pneumatosis. In
these five cases, patients did not have gastric ischemia and in
three of the five pneumatosis cases, a control CT showed
disappearance of the pneumatosis after nasogastric aspiration
(Fig. 5).
Fig. 3 62-year-old man with surgically confirmed gastric volvulus. a
Axial slice shows the antropyloric transition zone at the distal part of the
antrum (A) without any mass or bowel wall thickening (arrow). b Coronal
reconstruction shows the fundus (F) at a lower level than the antrum (A)
Discussion
We found CT to be highly sensitive and specific for the
diagnosis of gastric volvulus, using the presence of a
gastropyloric transition zone without any identifiable
obstacles combined with an abnormal location of the
antrum at the same level or higher than the fundus as
diagnostic criteria.
These two findings, considered separately, are highly sen-
sitive but lacked specificity. In our series, five patients with a
gastropyloric identifiable transition point, including two
patients without any mass or wall thickening at this
point, were found in the control group, and one patient
with the antrum at the same level or higher than the fundus
was present in the control group. However the combination of
these two findings allows one to easily diagnose or exclude
gastric volvulus with 100 % sensitivity and specificity, and
high interobserver agreement.
 Eur Radiol

Fig. 4 87-year-old man with surgically confirmed gastric volvulus. a Fig. 5 95-year-old woman with parietal and portal pneumatosis compli-
Coronal reconstruction shows the antrum (A) and the fundus (F) at the cating gastroparesis. a Unenhanced axial CT slice shows a parietal
same level whereas the body (B) is lower. b Axial slice shows the (arrowhead) and portal (arrow) pneumatosis. b 5 days later, the
antropyloric transition zone (arrow) pneumatosis has disappeared and the gastric wall is normally enhanced

The different published case reports of CT features in reliability of this finding since, although the specificity was
gastric volvulus describe a reversed position of the greater perfect, the sensitivity was very low (30 %) with slight inter-
and lesser gastric curvatures. Our study did not confirm the observer agreement.
In contrast to the direct findings of gastric rotation, a whirl
finding was never identified in our gastric volvulus popula-
Table 2 Association between CT signs of ischemia and bowel ischemia tion. This could seem in contradiction with reports describing
at pathology
CT findings in other sites of volvulus such as caecal or
CT signs of ischemia OR 95 % CI p value sigmoid volvulus, in which a whirl finding was described in
73 % and 58 % of cases, respectively [16, 17]. We hypothesize
Perigastric intraperitoneal fluid 0.21 0.01–4.47 0.32 that the epiploon, which is shorter than the mesentery, cannot
Pneumoperitoneuma _ _ _ twist, as is the case in colic volvulus, which results in a tightly
Gastric wall pneumatosis 0.21 0.01–4.47 0.32 twisted mesentery along the rotation axis of the volvulus [18].
Lack of gastric wall enhancementb <0.001 <0.001 to >999.99 0.96 Regarding risk factors, we found a significant 80 % rate of
Hepatic, splenic or pancreatic _ _ _ paraoesophageal hernia in patients with gastric volvulus. This
ischemiaa
is in accordance with published data showing that most pa-
a
No case of free pneumoperitoneum and of hepatic, splenic or pancreatic tients with volvulus have secondary volvulus, usually due to
ischemia hiatus hernia. A study published in 2000 [8] found that
b
9 CT examinations were performed without contrast paraoesophageal hiatal hernia was the most common
Eur Radiol
predisposing factor of gastric volvulus present in 28 of 36
cases (78 %). By contrast, a wandering spleen or agenesis of
the left liver, reported to be factors associated with gastric
volvulus [12, 19], were not encountered in our gastric volvu-
lus population.
The role of CT in the evaluation of ischemia in patients
with gastric volvulus has never been reported to date, although
the possibility of ischemia and perforation is the main risk in
gastric volvulus with necrosis, as reported in 5–28 % of cases
[5] and the mortality rate may reach 50 % [20]. Although we
found no relationship between CT signs and surgically con-
firmed ischemia, no conclusions can be drawn from our series
because of the low number of patients with ischemia compli-
cating gastric volvulus. By contrast, when volvulus was not
present, our study confirmed reported data on the possibility
of non-ischemic gastric pneumatosis consecutive to gastric
dilatation, which we have noted in five cases, and may be
efficiently managed by a nonoperative decompression
[21, 22].
Our study had several limitations. First and foremost, the
sample size analysed was small. The low disease prevalence
limited the power of statistical analysis, with large standard
deviation for the different findings we evaluated. However,
our series of 10 volvulus patients compares favourably with
published studies on CT of gastric volvulus which include a
maximum of three patients [5]. Furthermore by including a
control group and by performing CT-reading blinded to the
final diagnosis, we could assess the specificity of the different
findings, avoiding bias due to readers being aware of the final
diagnosis.
Second, we did not correlate CT findings with the anatom-
ical type of volvulus, i.e. organoaxial or mesenteroaxial, since
this information was not available in the majority of cases. In a
retrospective study including 26 patients with an operated
acute gastric volvulus, the anatomical classification was re-
corded in only 10 patients [8]. In clinical practice, the abdom-
inal surgical approach with part of the stomach within the
thorax often makes it difficult to accurately evaluate the ana-
tomic type of the volvulus, especially since these two forms
may be combined.
Third, we analysed surgically confirmed cases only
and thus could have introduced a selection bias in
favour of more severe disease. However, our policy was
to treat by surgery all patients with a suspicion of acute gastric
volvulus.
Fourth, we identified the control group by using the orig-
inal CT interpretation noting a gastric distension not explained
by a small bowel obstruction or an ileus. Ideally, the control
group would have exhaustively and consecutively includ-
ed all patients in whom gastric volvulus was a clinical
concern, but this was impossible because of the retrospec-
tive nature of our study and because gastric volvulus is seldom
clinically suspected.
Fifth, we did not focus our CT analysis on the position of
the right gastric vein, which has been described as a useful
marker for localizing the major curvature [5], since coronal
views were available to monitor the gastric curvature and also
a significant number of patients were scanned without intra-
venous contrast (9/30, 30 %).
In conclusion, CT is reliable for diagnosing acute gastric
volvulus. By using the presence of a gastropyloric transition
zone without any identifiable obstacles combined with an
abnormal location of the antrum at the same level or higher
than the fundus as diagnostic criteria, CT is highly sensitive,
specific and reproducible. Gastric volvulus diagnosis is facil-
itated by the presence of a paraoesophageal hernia with her-
niation of the antrum in the left hemithorax encountered in the
majority of patients and easily identified on CT. Further in-
vestigations should now be carried out to differentiate
organoaxial from mesenteroaxial gastric volvulus, to evaluate
the prognosis value of this differentiation and to analyse the
value of CT for diagnosing ischemia in acute gastric volvulus.
Acknowledgments The scientific guarantor of this publication is
P. Taourel. The authors of this manuscript declare no relationships with
any companies, whose products or services may be related to the subject
matter of the article. The authors state that this work has not received any
funding. N. Molinari kindly provided statistical advice for this manu-
script. One of the authors has significant statistical expertise. No complex
statistical methods were necessary for this paper. Institutional review
board approval was obtained. Institutional review board approval was
not required because of the retrospective nature of the study. Written
informed consent was waived by the institutional review board. Method-
ology: retrospective, case–control study, performed at one institution.
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