Presentation
Profuse vomiting.
Patient Data
Radiographs taken following administration of iodinated contrast material per NGT by the surgeon at the emergency department.
NGT looped in large hiatal hernia. Hernia contains two air-fluid levels. Contrast material seen under left hemidiaphragm and in several small bowel loops.
CT scan done several hours after the radiographs.
Technical: The above scan was acquired in delayed phase because the patient moved during the original scan.
Large paraesophageal hernia containing stomach in organoaxial position and distal transverse-proximal descending colon. Nasogastric tube in stomach. No gastric or intestinal dilatation. Contrast material reaches rectum.
Several tiny hypodense hepatic lesions too small to characterize. Numerous peripelvic renal cysts bilaterally.
Two air-fluid levels seen in a large hiatal hernia on a chest radiograph taken 3 years earlier.
Case Discussion
Despite presence of contrast material in the small bowel and no intestinal dilatation on abdominal radiographs (upright PA not shown), an abdominal CT was ordered.
At CT, the stomach lies in a paraesophageal hernia in an organoaxial position 1, i.e. incomplete chronic volvulus. Chronicity is demonstrated by a radiograph taken 3 years earlier, where two air-fuid levels are also seen in the large hiatal hernia. Other than a previous radiograph, signs that this is not true gastric volvulus are the absence of Borchardt's triad, a non-dilated stomach and passage of contrast material into the rectum (hence, no gastric outlet obstruction).
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