‘Back-and-Forth Stomach’ CT Imaging Findings of a Pathophysiologic Entity Causing Acute Gastric Volvulus

Abstract

Background: Gastric volvulus (GV) is a life-threatening emergency condition that prompts emergent surgical management. With the advent of high-resolution computed tomography (CT), the role of radiologists in its diagnosis has become essential. Although many cases of GV have been described in the literature, its pathophysiology is still poorly understood. In addition, there is substantial terminological confusion with associated entities such as paraesophageal hernia, upside-down stomach, organo-axial or chronic GV. Methods: We conducted a retrospective review of clinical, radiological findings and other relevant data for seven patients with previous radiological diagnoses of a large hiatus hernia who presented with acute GV to the emergency department of our institution. We report data on age, sex, medical history, clinical presentation, imaging, treatment and outcomes for each case. Results: The CT findings at acute presentation showed the antrum lying above the diaphragm and dilated fundus below the diaphragm. By comparing the position of the stomach at acute presentation with previous imaging examinations, we confirmed a hypothesis put forward by a few authors decades ago that re-herniation of the gastric fundus into the abdomen is a common pathophysiologic trigger leading to acute GV. This hypothesis has not been supported by modern imaging examinations. Conclusions: We have provided imaging evidence supporting that the pathophysiology of many GVs is based on caudal re-descent of hiatal hernia into the abdominal cavity. Given the terminological disparity used in the literature in this context, we believe it appropriate to introduce and extend the term ‘back-and-forth stomach’ to refer to this type of GV.

Redescending Stomach: A Rare and Potentially Lethal Complication of Gastric Herniation

“…She was administered the best supportive care and passed away within 24 hours of admission. of the distal stomach [1], [4]. This phenomenon is illustrated by the consecutive abdominal CT scans and cinematic rendering of this case (Figures 1, 3, and 4).…”

“…A redescending gastric fundus as the cause of strangulation has been described in fluoroscopic studies in an article from 1976 [1]. Interestingly, since then, only one small case series seems to have been published on the subject [4].…”

“…A less recognized cause of acute gastric strangulation is the redescent of the gastric fundus through the hernial ring. This is probably triggered by a sudden increase in intrathoracic pressure, causing the fundus to migrate back into the abdominal cavity [4]. As a result, the fundus cannot drain its contents through the constricted hernia neck into the supradiaphragmatic antrum.…”

Upside-down stomach in paraesophageal hernia: A case report

“…Gastric volvulus can occur along the organ and mesenteric axes, with the latter being relatively uncommon. [ 1 , 2 ] In the acute phase, upside down stomach primarily presents with gastrointestinal symptoms. It is crucial to promptly and accurately diagnose this condition, as ischemia, necrosis, and perforation may be observed in cases of incarcerated stomach with gastric volvulus.…”

The ‘back‐and‐forth stomach’. Increasing evidence of its role in the pathophysiology of gastric volvulus

“…After careful analysis of the case, we came to the conclusion that the pathophysiological mechanism leading to GV in this patient was analogous to the previously described 'back-and-forth stomach'. 4 The patient was managed surgically with partial resection and fundoplication, and evolved favourably.…”