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EDUCATION EXHIBIT 1281

Volvulus of
the
Gastrointestinal Tract:
Appearances at
Multi- modality
ONLINE-ONLY CME
Imaging1
See www.rsna
.org/education
/rg_cme.html Christine M. Peterson, MD • John S. Anderson, MD • Amy K.
Hara, MD Jeffrey W. Carenza, MD • Christine O. Menias, MD

LEARNING Volvulus of the gastrointestinal tract, a clinically relevant cause of

OBJECTIVES acute or recurring abdominal pain in adults, remains a diagnostic di-
After reading this lemma for radiologists in a large number of cases. The clinical
article and taking
the test, the reader symp- toms associated with volvulus are often nonspecific and
will be able to: include pain and nausea with vomiting.Yet referring clinicians often
 List the risk fac- rely on radi- ologists to make the diagnosis; volvulus is rarely
tors for develop-
ment of volvulus of diagnosed clinically. Radiography, fluoroscopy, and computed
the stomach, small tomography are the imaging methods most often used for this
bowel, and colon.
 Identify the
purpose. Prompt diagnosis is critical to avoid life-threatening
most common complications such as bowel ischemia and in- farction. Thus, it is
imag- ing
appearances
useful for radiologists to be familiar with the vari- ous appearances
of gastrointestinal of volvulus throughout the gastrointestinal tract.
volvulus.
©
RSNA, 2009 • radiographics.rsna.org
 Describe
common subtypes
of volvulus of the
stomach and colon.

TEACH ING
POINTS
See last page

Abbreviation: GI = gastrointestinal

RadioGraphics 2009; 29:1281–1293 • Published online 10.1148/rg.295095011 • Content Code:

1
From the Department of Radiology, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, 500 University Dr, H066, Her-
shey, PA 17033-0850 (C.M.P.); Colorado Permanente Medical Group, Denver, Colo (J.S.A.); Department of Diagnostic Radiology, Mayo Clinic,
Scottsdale, Ariz (A.K.H.); Texas Radiology Associates, Plano, Tex (J.W.C.); and Mallinckrodt Institute of Radiology, Washington University
School of Medicine, St Louis, Mo (C.O.M.). Presented as an education exhibit at the 2006 RSNA Annual Meeting. Received January 15, 2009;
revision requested February 11 and received June 16; accepted June 17. A.K.H. has license and research agreements with General Electric; all
other authors have no financial relationships to disclose. Address correspondence to C.M.P. (e-mail: [email protected]).
©
RSNA, 2009
 1282 September-October 2009 radiographics.rsna.org

Introduction
Volvulus of the gastrointestinal tract, a clinically
relevant cause of acute or recurring abdominal
pain in adults, often poses a diagnostic dilemma
for radiologists. The clinical symptoms associ-
ated with volvulus commonly are nonspecific
and include pain, nausea, and vomiting. Because
it is rarely diagnosed clinically, clinicians often
con- sult radiologists for diagnostic evaluations;
Figure 1. Organoaxial volvulus. Diagram shows
radi- ography, fluoroscopy, and computed
the rotation of the stomach along its long axis. GC =
tomography (CT) are the modalities most greater curvature, LC = lesser curvature.
frequently em- ployed. Prompt diagnosis is
critical to avoid life- threatening complications
of prolonged volvulus such as bowel ischemia
and infarction. This ar- ticle highlights the
different clinical features and common imaging
findings of volvulus throughout the
gastrointestinal tract.

Gastric Volvulus
The stomach is a relatively uncommon site of
volvulus. Patients with acute gastric volvulus typi-
cally present with epigastric pain, nausea, and Figure 2. Mesenteroaxial volvulus. Diagram shows
vomiting. A useful clinical triad for identifying the stomach twisting along its short axis. A = gastric
gastric volvulus, the Borchardt triad consists of antrum, GEJ = gastroesophageal junction.
sudden epigastric pain, intractable retching, and
inability to pass a nasogastric tube into the stom-
ach (1).
Gastric volvulus is usually divided into two becomes dilated and fills with fluid. If positive
main subtypes: organoaxial and oral contrast material is administered, it is re-
mesenteroaxial. Organoaxial volvulus is far tained in the stomach. However, many patients
more common than mesenteroaxial volvulus have a less severe, incomplete or partial volvu- Teaching Point
and accounts for ap- proximately two-thirds of lus—a rotation of less than 180. In these cases,
cases of gastric volvu- lus. Both are surgical ingested contrast material may pass through the
emergencies and warrant prompt diagnosis and stomach and into the duodenum. Patients with a
redundant paraesophageal hernia are predisposed
Teaching Pointtreatment.
Organoaxial volvulus occurs when the stom- to developing a secondary rotation of the stom-
ach rotates along its long axis and becomes ach along its long axis. These patients usually
obstructed, with the greater curvature being dis- lack clinical symptoms of obstruction and exhibit
placed superiorly and the lesser curvature no evidence of obstruction at imaging. In such
located more caudally in the abdomen (1–3). cases, it is more accurate to describe the stomach
The antrum rotates anterosuperiorly, and the as having an organoaxial position rather than an
fundus rotates posteroinferiorly. In adults, organoaxial volvulus, although an organoaxial
organoaxial volvulus most commonly occurs in position of the stomach predisposes it to future
the setting of a post- traumatic or paraesophageal volvulus. It is unclear whether asymptomatic pa-
hernia that allows the stomach to move tients should be treated or followed up clinically.
abnormally along its long axis (4). If the In general, the acuity and severity of symptoms
volvulus is severe or complete— meaning that dictate management. In children, a large Boch-
dalek hernia is a predisposing factor for gastric
the twist is greater than 180—gas- tric outlet
volvulus (Fig 1) (4).
obstruction occurs, and the stomach
 Figure 3. Organoaxial volvulus. (a) Upper GI image shows an upward rotation of the stomach along its
long axis, which results in inversion of the greater curvature (GC) above the lesser curvature (LC). Arrow =
pylorus. (b) CT image shows the transverse lie of the stomach, which has herniated into the chest. Arrow =
pylorus.

Figure 4. Primary organoaxial volvulus in a new-

born. Upper GI image shows inversion of the greater
(GC) and lesser (LC) curvatures of the stomach.

Mesenteroaxial volvulus is much less com-

mon than organoaxial volvulus. It occurs when
the stomach rotates along its short axis, with Figure 5. Mesenteroaxial volvulus. Anteroposterior
upper GI image shows displacement of the gastric an-
resultant displacement of the antrum above the
trum (A) above the gastroesophageal junction (arrow).
gastroesophageal junction (1–3). Rotation is usu- The gastric body (B) and pylorus (P) also are seen.
ally partial (less than 180) and is not associated
with an underlying diaphragmatic defect (Fig
2). However, some patients may have a If a diagnosis is made and surgical repair is
Teaching Point
complex gastric volvulus, with both performed soon after the onset of symptoms,
organoaxial and mes- enteroaxial components. gastric ischemia usually can be avoided.
Radiographic findings of gastric volvulus in- However, if there is a delay in patient
clude herniation of a large portion of the stom- presentation, diagno- sis, or intervention, gastric
ach above the diaphragm, often with differential ischemia may result,
air-fluid levels (5). An upper gastrointestinal
(GI) series may be performed to evaluate the
rotation of the stomach, as well as to detect
passage of ingested oral contrast material into
the duodenum. Multi–detector row CT often is
performed in the setting of epigastric pain and
vomiting and can help confirm the rotation of
the herniated stomach and the transition point
(Figs 3–5).
 Figure 6. Perforated gastric volvulus in a 73-year-old man with abdominal pain. Scout radiograph (a) and
coronal CT image (b) show gastric distention and pneumoperitoneum (arrows in a) due to a perforated gastric
volvulus, the presence of which was confirmed at surgery. Perforation of a gastric volvulus is an uncommon
complication that re- sults from gastric ischemia. GC = greater curvature, LC = lesser curvature.

Midgut volvulus in an infant.

GI image shows that the small bowel lies in the right side of the abdomen and does not cross the midline. (b) Lateral upper GI image shows the typical twisting cork
mal jejunum. (c) Lateral up- per GI image obtained in a different pa- tient also shows the classic corkscrew-like appearance.
 Figure 8. Midgut volvulus in a patient with cardiovascular collapse. CT images (b is slightly more caudal than
a) obtained emergently show bowel dilatation and mucosal hyperattenuation, findings indicative of global small-
bowel ischemia. There is a twist at the root of the small-bowel mesentery, and an abnormal relationship between
the supe- rior mesenteric artery (long arrow) and the superior mesenteric vein (short arrow) is seen.

which can lead to necrosis, perforation, medias- are usually the preferred imaging tests when
tinitis, and peritonitis (Fig 6). midgut volvulus is suspected. On upper GI
images, the liga- ment of Treitz normally is
Midgut Volvulus located at or to the left of the left L1 pedicle. In
Midgut volvulus is a different clinical entity and patients with malrotation, the ligament of Treitz is
is most common in children; 60%–80% of those abnormally positioned, usually below and to the
affected present with bilious vomiting in the 1st right of the left L1 pedicle. In the presence of a
month of life (6). However, as the use of CT in midgut volvulus, the twisted segment (usually a
emergency departments increases, midgut volvu- proximal segment) of small bowel has a
lus is increasingly being recognized in adults. characteristic corkscrew-like appearance on
Malrotation of the small bowel is the major fluoro- scopic images (Fig 7) (6).
predisposing factor for midgut volvulus. In a Ultrasonography (US) is sometimes helpful in
mal- rotation, there is abnormal fixation of the that an abnormal positional relationship between
small bowel mesentery, which results in an the superior mesenteric vein and artery may be
abnormally short mesenteric root. This allows appreciated, with the vein located to the left of
the small bowel to twist around its mesentery, the artery, which is the opposite of its usual ori-
causing obstruction and possibly ischemia of the entation (6,8). However, US does not directly
bowel. Midgut volvu- lus often occurs early in show the abnormal position of the bowel and is
life, and in such cases sur- gery is performed to rarely used in this clinical setting.
repair the malrotation. How- ever, volvulus also Familiarity with the CT findings of midgut
eachi
T ng may occur in adulthood, and in some cases may
Point
volvulus is important, because many patients
manifest as chronic intermittent abdominal pain present with nonspecific symptoms and are first
that resolves when the volvulus spontaneously evaluated with cross-sectional imaging. At CT,
reduces. If it does not spontane- ously reduce, a swirling of vessels in the mesenteric root may
patients at any age may present with abdominal be seen at the site of the volvulus (6,7,9). The
pain, nausea, and vomiting (1,7).
abnormal relationship between the superior mes-
Conventional radiography usually yields non- enteric artery and vein, an ectopic location of the
specific findings and is rarely helpful in making a majority of small bowel loops, and an abnormal
diagnosis. On the other hand, fluoroscopic upper position of the ligament of Treitz (which was de-
GI and small-bowel examinations may reveal the scribed earlier) also may be seen (Fig 8).
characteristic abnormal position of most of the
small bowel in the right abdomen and the resultant
abnormal location of the ligament of Treitz. These
 Figure 9. Cecal volvulus in a 74-
year- old woman with abdominal pain.
Ra- diograph shows dilated air-filled
cecum (arrow) in the left upper
quadrant.

Figure 10. Cecal volvulus in an elderly woman with abdominal pain. (a) Coronal reformatted CT
image shows dilated cecum (arrow) in the left upper quadrant of the abdomen. The cecum is displacing
the contrast material–filled stomach superiorly, and there is obstruction of the small bowel. (b) Axial
CT image shows that the dilated cecal loop (arrow) has twisted on its mesentery and is located ectopi-
cally in the upper abdomen.

Colonic are less common and also may predispose pa-

Volvulus tients to cecal volvulus (1,10).
Cecum As opposed to volvulus in other locations,
Teaching Point
Cecal volvulus accounts for 25%–40% of all colonic volvulus often has a characteristic ap-
cases of colonic volvulus. Congenital anomalies pearance at conventional radiography, which
of colonic fixation usually are present and may be sufficient for a diagnosis in a large
include an abnormal fixation of the right colon to percentage of patients. A dilated gas-filled
the ret- roperitoneum and abnormal motility of viscus, usually located ectopically in the left
the right colon. Factors that result in dilatation of upper quadrant or mid abdomen, is a
the right colon, such as pregnancy and recent radiographic feature of cecal volvulus.
colonoscopy, However, it is important to recognize that the
cecum may be displaced anywhere in the
abdomen (11). Proximal obstruction may or
may
 Figure 11. Cecal volvulus. Contrast-
enhanced CT image shows dilated,
fluid- and gas-filled cecum at the lower
midline. Pneumatosis of the cecum (ar-
rows) also is seen. The diagnosis was
confirmed at exploratory surgery.

Figure 12. Cecal volvulus in an elderly patient with abdominal cramps. (a) CT image shows dilated
fluid-filled cecum in the lower abdomen. The proximal small bowel also is dilated. (b) Image acquired in a
contrast material enema study shows the classic beaklike appearance of the bowel at the twist (arrow).

not be present, depending on the acuity of the patients with suspected cecal volvulus proceed
volvulus (Figs 9, 10) (1). to CT if further imaging is required. At CT,
A diagnosis of cecal volvulus often is con- the abnormally positioned cecum often appears
firmed with a contrast material enema study or in the upper mid and left abdomen and can be
CT. During the enema, the distal colon usually traced back to the level of the volvulus, which
is decompressed, and there is a beaklike taper- appears as an area of swirling of the bowel
ing at the level of the volvulus. It usually is not
and its mesentery, a finding also known as the
possible for much contrast material to pass
“whirl” sign (Figs 11–16) (12).
beyond the volvulus into the more dilated proxi-
Cecal bascule, first described in the early
mal colon and terminal ileum. For patients in
1900s, refers to abnormal location of the dilated
whom cecal volvulus is suspected on the basis
cecum in the mid abdomen and results from up-
of radiographic findings, a contrast material
ward folding of the cecum on itself, without as-
enema study may help confirm the diagnosis.
sociated twisting. Cecal bascule occurs when the
However, given the widespread availability of
cecum is loosely attached to its mesentery. Some
CT and the relative speed with which it can be
performed compared with that of the enema
study, most
 Figure 13. Cecal volvulus. (a) Topographic CT image shows a dilated air-filled viscus in the midline
(arrow) and a small-bowel obstruction. (b) Contrast-enhanced CT image shows displacement of the dilated
fluid- filled cecum in the right upper quadrant (arrow), with resultant small-bowel obstruction.

Figure 14. The whirl sign of cecal volvulus. (a) Contrast-enhanced CT image shows a dilated, stool-filled
cecum in the left upper quadrant of the abdomen (arrow). (b) Contrast-enhanced CT image shows that the twist
involves the ileum, which lies in the right lower quadrant (arrow). Note the whorled appearance of the mesenteric
vessels within the twist. Mesenteric stranding and edema also are seen.

Figure 15. Infarcted cecal volvulus in a

20-year-old woman. Contrast-enhanced CT
image shows a dilated cecum located high
in the midline. Note the ring of gas in the
cecal
wall (arrows), a finding suggestive of pneuma-
tosis. The diagnosis of an infarcted cecal vol-
vulus was confirmed at exploratory surgery.
Figure 16. Cecal volvulus. Axial (a) and coronal (b) reformatted CT images show the distended cecum in
the left upper quadrant of the abdomen (* in a). The mesenteric twist, which in this case involves the terminal
ileum, is most easily seen within the circled area in b.

Figure 17. Transverse colon volvulus in a 57-year-old

woman with a 7-year history of intermittent abdominal pain
and a 30-year history of laxative use. (a, b) CT images (b
is slightly more caudal than a) show a whirl sign adjacent to
the transverse colon (arrow). (c) Image acquired during an
en- ema shows classic beaklike narrowing of the transverse
colon at the volvulus (arrow).

with the highest mortality. It occurs in the

setting of abnormal fixation of a long transverse
colon. Conventional radiography is seldom
helpful in diagnosing this entity. As in cases of
cecal volvu- lus, a contrast material enema
study shows the characteristic beaklike tapering
have argued that cecal bascule is a form of of the colon at the level of the twist. However,
cecal adynamic ileus that may lead to because volvulus of the transverse colon is rare
perforation, de- pending on duration of and not usually ex- pected, the diagnosis is
symptoms (13). often made at CT, which shows bowel
obstruction and the classic mesen- teric twist
Transverse Colon (Fig 17).
The transverse colon is the rarest site of colonic
volvulus (<5%–10% of cases), but it is associated
 Figure 18. “Northern exposure” sign in a
52-year-old man with abdominal pain. Erect
radiograph shows the displacement of the
sig- moid colon (arrow) above the transverse
colon (Tr). This sign was first observed as
extension of the apex of the sigmoid colon
cephalad to the transverse colon on supine
radiographs.

Figure 19. Sigmoid volvulus. (a) Supine radiograph shows the sigmoid colon arising from the pelvis, with
its apex in the left upper abdomen. The interposed loops produce the white-stripe sign (arrow). (b) Image
acquired in a contrast material enema study shows abrupt termination of the contrast material column in a
beaklike point.

Sigmoid Colon cause of large-bowel obstruction in the absence

The sigmoid is the most common site of colonic
of neoplasm and diverticular disease. However, in
volvulus and accounts for 60%–75% of all cases developing countries, sigmoid volvulus causes a
of colonic volvulus. It is generally considered to
majority of bowel obstructions and is presumably
be an acquired condition because its prevalence caused by relatively high-fiber diets. It is also the
increases among those with chronic constipation
most common cause of bowel obstruction during
and sigmoid colonic redundancy due to a high- pregnancy.
fiber diet, pregnancy, hospitalization or institu-
Because patients usually present with nonspe-
tionalization, or Chagas disease (1,10,14). In de-
cific abdominal pain and symptoms of obstruc-
veloped countries, sigmoid volvulus is a
tion, conventional radiography often is performed
common
as part of the initial work-up. Radiographic find-
ings that may be diagnostic of sigmoid volvulus
include a large air-filled bowel loop, which rep-
Figure 20. Sigmoid volvulus in a 46-year-old woman with abdominal pain. (a) Radiograph shows an
air-filled, dilated viscus (arrow) arising from the pelvis. (b) Coronal CT image shows the whirl sign in
the sigmoid mesocolon (arrow). A contrast material enema study helped confirm the diagnosis.

Figure 21. Sigmoid volvulus. Coronal CT images obtained with soft-tissue (a) and lung (b) window
settings show the whirl sign (arrow in a) and the classic beak sign (arrow in b) at the level of the twist.
The diagnosis was confirmed at endoscopy.

resents the sigmoid colon, arising from the fers to the coffee bean–like shape that the
pelvis and extending cranially beyond the level dilated sigmoid colon may assume (10,16).
of the transverse colon (the “northern exposure” Similarly, the “closed-loop” and “three-line” or
sign) (Figs 18–23) (10,15). Other useful “white-stripe”
radiographic features include the “coffee bean”
sign, which re-
Figure 22. Sigmoid volvulus. (a) Radiograph shows a dilated sigmoid colon arising from the
pelvis, with its apex in the right upper quadrant of the abdomen (arrow). (b) Coronal CT image
shows the characteristic whirl sign at the level of the volvulus (arrow).

Figure 23. Sigmoid volvulus. (a) Radiograph shows a dilated viscus arising from the pelvis
and ascending above the transverse colon. (b) CT image shows the site of the twist (arrow).
signs describe the U-shaped closed-loop appear- 3. Eisenberg R, Levine M. Miscellaneous
ance of the colon, which is dilated between the abnormali- ties of the stomach and duodenum.
two points of obstruction at the site of the volvu- In: Gore RM, Levine MS, eds. Textbook of
lus; and the obliquely oriented vertical white gastrointestinal radiol- ogy. 2nd ed. Philadelphia,
lines that represent the opposed walls of the Pa: Saunders, 2000; 675.
4. Godshall D, Mossallam U, Rosenbaum R.
dilated bowel loop (the center line) and the outer Gastric volvulus: case report and review of the
walls of the bowel loop on either side (11,17). literature. J Emerg Med 1999;17(5):837–840.
In cases in which the diagnosis is uncertain, 5. Menuck L. Plain film findings of gastric
a water-soluble contrast material enema study volvulus herniating into the chest. AJR Am J
or CT may be performed. In an enema study, a Roentgenol 1976;126(6):1169–1174.
6. McAlister WH, Kronemer KA. Emergency
beak-shaped area often is seen at the level of
gastro- intestinal radiology of the newborn.
the distal aspect of the twist in the sigmoid, Radiol Clin North Am 1996;34(4):819–844.
beyond 7. Bernstein SM, Russ PD. Midgut volvulus: a
which no contrast material passes. In addition to rare cause of acute abdomen in an adult patient.
providing diagnostic information, the enema AJR Am J Roentgenol 1998;171(3):639–641.
may help achieve reduction of the volvulus. At 8. Shimanuki Y, Aihara T, Takano H, et al.
Clockwise whirlpool sign at color Doppler US:
CT, the abnormal position of the sigmoid colon
an objective and definite sign of midgut
and volvulus. Radiology 1996;199(1):261–264.
swirling of the mesentery at the level of the 9. Fisher JK. Computed tomographic diagnosis of
volvu- lus are visible. As with cases of volvulus volvulus in intestinal malrotation. Radiology
involving other sites in the GI tract, coronal and 1981; 140(1):145–146.
sagittal reformations may be useful for locating 10. Ott DJ, Chen MY. Specific acute colonic
the mes- enteric swirl and evaluating the disorders. Radiol Clin North Am 1994;32(5):871–
884.
orientation of the rotated bowel segment. 11. Freeny PC, Stevenson GW, eds. Margulis and
Burhenne’s alimentary tract radiology. 5th ed.
Summary St. Louis, Mo: Mosby-Year Book, 1994; 362–
Volvulus may involve any portion of the GI 365, 2059–2061.
tract from the stomach to the colon and is an 12. Frank AJ, Goffner LB, Fruauff AA, Losada RA.
impor- tant cause of acute or recurring Cecal volvulus: the CT whirl sign. Abdom
Imaging 1993;18(3):288–289.
abdominal pain. Because a delay in diagnosis 13. Fazel A, Verne GN. New solutions to an old
can have devastating consequences, including prob- lem: acute colonic pseudoobstruction. J
bowel ischemia and in- farction, prompt Clin Gas- troenterol 2005;39(1):17–20.
diagnosis is essential. The clini- cal symptoms 14. Jones IT, Fazio VW. Colonic volvulus: etiology
of volvulus often are nonspecific, and and management. Dig Dis 1989;7(4):203–209.
15. Javors BR, Baker SR, Miller JA. The northern
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17. Baker SR. The abdominal plain film. East
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This article meets the criteria for 1.0 AMA PRA Category 1 Credit TM.To obtain credit, see www.rsna.org/education
/rg_cme.html.
 RGVolume 29 Number 5September-October 2009 reterson et al
RadioGraphics

Volvulus of the Gastrointestinal Tract: Appearances at

Multimodality Imaging

Christine M. Peterson, MD ct al

RadioGraphics 2009; 29:1251-129s • rublished online 10.1148/rg.29509501 I • Content Code:

rage 1282
Organoaxial volvulus occurs when the stomach rotates along its long axis and becomes obstructed,
with the greater curvature being displaced superiorly and the lesser curvature located more caudally in
the abdomen.

rage 1282
Many patients have a less severe, incomplete or partial volvulus---a rotation of less than 180°. In these
cases, ingested contrast material may pass through the stomach and into the duodenum. Patients with
a redundant paraesophageal hernia are predisposed to developing a secondary rotation of the stomach
along its long axis. These patients usually lack clinical symptoms of obstruction and exhibit no
evidence of obstruction at imaging. In such cases, it is more accurate to describe the stomach as
having an organoaxial position rather than an organoaxial volvulus, although an organoaxial position
of the stomach predisposes it to future volvulus. It is unclear whether asymptomatic patients should
be treated or followed up clinically. In general, the acuity and severity of symptoms dictate
management. In children, a large Bochdalek hernia is a predisposing factor for gastric volvulus.

rage 1282
Some patients may have a complex gastric volvulus, with both organoaxial and mesenteroaxial
components.

rage 1285
Volvulus also may occur in adulthood, and in some cases may manifest as chronic intermittent
abdominal pain that resolves when the volvulus spontaneously reduces. If it does not spontaneously
reduce, patients at any age may present with abdominal pain, nausea, and vomiting.

rage 1286
As opposed to volvulus in other locations, colonic volvulus often has a characteristic appearance at
conventional radiography, which may be sufficient for a diagnosis in a large percentage of patients.