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).