A diagnostic twist: imaging of organoaxial gastric volvulus

An 81-year-old female presented to the emergency department with no prior history of abdominal trauma, abdominal surgery, or known hiatal hernia. All personal identifiers have been removed to maintain patient confidentiality. She reported acute-onset severe epigastric pain and recurrent non-bilious vomiting for one day, accompanied by abdominal distension and inability to tolerate oral intake. Attempts at nasogastric tube insertion were unsuccessful. On examination, she was dehydrated, with upper abdominal tenderness and mild tympany. Laboratory investigations were largely unremarkable except for mild leukocytosis. Contrast-enhanced computed tomography of the abdomen and lower chest demonstrated protrusion of the entire stomach along with the gastroesophageal junction through the diaphragmatic hiatus into the intrathoracic cavity. The stomach was twisted along its longitudinal axis, with the antrum and pylorus positioned superior to the gastroesophageal junction and the greater curvature located above the lesser curvature, consistent with organoaxial gastric volvulus. Sagittal images confirmed intrathoracic displacement of the stomach and proximal duodenum. There was no evidence of gastric ischemia, perforation, or pneumatosis. Differential considerations included paraesophageal hernia with gastric obstruction, pyloric obstruction secondary to peptic ulcer disease, and malignant gastric outlet obstruction.