Delayed diagnosis of intermittent mesenteroaxial volvulus of the stomach by computed tomography: a case report

Abstract

Introduction: Gastric volvulus is a rare condition. Presenting acutely, mesenteroaxial gastric volvulus has characteristic symptoms and may be easily detected with upper gastrointestinal contrast studies. In contrast, subacute, intermittent cases present with intermittent vague symptoms from episodic twisting and untwisting. Imaging in these cases is only useful if performed in the symptomatic interval.

Case presentation: We describe a patient with a long history of intermittent chest and epigastric pain. An earlier barium meal was not diagnostic. Diagnosis was finally secured during the current admission by a combination of (1) serum investigations, (2) endoscopy, and finally (3) computed tomography.

Conclusion: Non-specific and misleading symptoms and signs may delay the diagnosis of intermittent, subacute volvulus. Imaging studies performed in the well interval may be non-diagnostic. Elevated creatine kinase and aldolase of a non-cardiac cause and endoscopic findings of ischaemic ulceration and difficulty in negotiating the pylorus may raise the suspicion of gastric volvulus. In this case, abdominal computed tomography with spatial reconstruction was crucial in securing the final diagnosis.

Figure 1

(A) Supine abdominal radiograph showing a dilated spherical gastric shadow. (B) Right lateral decubitus abdominal radiograph showing a double gastric bubble, with the superior bubble representing the antrum (A) and inferior bubble being the fundus (F). Nasogastric tube indentation at the cardio-oesophageal junction (arrow) as it enters the stomach.

Figure 2

Acute gastric ulcers with surrounding mucosal ischaemia seen on gastroscopy.

Figure 3

(A) Coronal reconstructed computed tomography images showing a rotated, 'right-side up' position of the stomach with the pylorus (black arrow) superior to the cardio-oesophageal junction (white arrow). The fundus (F) is inferior and the antrum (A), superior. (B) Spleen (S) displaced inferior to the gastric body (G).

Figure 4

Adhesion band (marked *) between the stomach and the inferior surface of the diaphragm.

Figure 5

Diagrammatic representation of mesenteroaxial volvulus. The axis of rotation is the dotted line that bisects the greater and lesser curves of the stomach. The pyloro-antral region (P) rotates from right to left and anteriorly, with concomitant rotation of the fundus (F) distally, giving the stomach a 'right-side' up view (C, cardia; S, spleen).

Figure 6

Division of the adhesion band (marked *).

Figure 7

Anterior gastropexy.