Volvulus of the gastrointestinal tract, a clinically relevant cause of
acute or recurring abdominal pain in adults, remains a diagnostic di-
lemma for radiologists in a large number of cases. The clinical symp-
toms associated with volvulus are often nonspeciﬁ c and include pain
and nausea with vomiting. Yet referring clinicians often rely on radi-
ologists to make the diagnosis; volvulus is rarely diagnosed clinically.
Radiography, ﬂ uoroscopy, and computed tomography are the imaging
methods most often used for this purpose. Prompt diagnosis is critical
to avoid life-threatening complications such as bowel ischemia and in-
farction. Thus, it is useful for radiologists to be familiar with the vari-
ous appearances of volvulus throughout the gastrointestinal tract.
RSNA, 2009 • radiographics.rsna.org
List the risk fac-
tors for develop-
the stomach, small
bowel, and colon.
Identify the most
subtypes of volvulus
From the Department of Radiology, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, 500 University Dr, H066, Her-
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 ﬁ nancial relationships to disclose. Address correspondence to C.M.P. (e-mail: email@example.com).
the stomach twisting along its short axis. A = gastric
antrum, GEJ = gastroesophageal junction.
Figure 1. Organoaxial volvulus. Diagram shows
the rotation of the stomach along its long axis. GC =
greater curvature, LC = lesser curvature.
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 nonspeciﬁ c and
include pain, nausea, and vomiting. Because it is
rarely diagnosed clinically, clinicians often con-
sult radiologists for diagnostic evaluations; radi-
ography, ﬂ uoroscopy, and computed tomography
(CT) are the modalities most 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 ﬁ ndings of volvulus throughout
the gastrointestinal tract.
The stomach is a relatively uncommon site of
volvulus. Patients with acute gastric volvulus typi-
cally present with epigastric pain, nausea, and
vomiting. A useful clinical triad for identifying
gastric volvulus, the Borchardt triad consists of
sudden epigastric pain, intractable retching, and
inability to pass a nasogastric tube into the stom-
Gastric volvulus is usually divided into two
main subtypes: organoaxial and mesenteroaxial.
Organoaxial volvulus is far more common than
mesenteroaxial volvulus and accounts for ap-
proximately two-thirds of cases of gastric volvu-
lus. Both are surgical emergencies and warrant
prompt diagnosis and treatment.
Organoaxial volvulus occurs when the stom-
ach rotates along its long axis and becomes
obstructed, with the greater curvature being dis-
placed superiorly and the lesser curvature located
more caudally in the abdomen (1–3).
rotates anterosuperiorly, and the fundus rotates
posteroinferiorly. In adults, organoaxial volvulus
most commonly occurs in the setting of a post-
traumatic or paraesophageal hernia that allows
the stomach to move abnormally along its long
axis (4). If the volvulus is severe or complete—
meaning that the twist is greater than 180
becomes dilated and ﬁ lls with ﬂ uid. If positive
oral contrast material is administered, it is re-
tained in the stomach.
However, many patients
have a less severe, incomplete or partial volvu-
lus—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 stom-
ach 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 pa-
tients should be treated or followed up clinically.
In general, the acuity and severity of symptoms
dictate management. In children, a large Boch-
dalek hernia is a predisposing factor for gastric
volvulus (Fig 1) (4).
gastric volvulus, with both organoaxial and mes-
Radiographic ﬁ ndings of gastric volvulus in-
clude herniation of a large portion of the stom-
ach above the diaphragm, often with differential
air-ﬂ uid 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 conﬁ rm the rotation of
the herniated stomach and the transition point
If a diagnosis is made and surgical repair is
performed soon after the onset of symptoms,
gastric ischemia usually can be avoided. However,
if there is a delay in patient presentation, diagno-
sis, or intervention, gastric ischemia may result,
born. Upper GI image shows inversion of the greater
upper GI image shows displacement of the gastric an-
trum (A) above the gastroesophageal junction (arrow).
The gastric body (B) and pylorus (P) also are seen.
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 =
mon than organoaxial volvulus. It occurs when
the stomach rotates along its short axis, with
resultant displacement of the antrum above the
gastroesophageal junction (1–3). Rotation is usu-
ally partial (less than 180
°) and is not associated
with an underlying diaphragmatic defect (Fig
However, some patients may have a complex
CT image (b) show gastric distention and pneumoperitoneum (arrows in a) due to a perforated gastric volvulus, the
presence of which was conﬁ rmed at surgery. Perforation of a gastric volvulus is an uncommon complication that re-
sults from gastric ischemia. GC = greater curvature, LC = lesser curvature.
bowel lies in the right side of the abdomen
and does not cross the midline. (b) Lateral
upper GI image shows the typical twisting
corkscrew-like appearance of a volvulus
of the proximal jejunum. (c) Lateral up-
per GI image obtained in a different pa-
tient also shows the classic corkscrew-like
obtained emergently show bowel dilatation and mucosal hyperattenuation, ﬁ ndings 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-
tinitis, and peritonitis (Fig 6).
Midgut volvulus is a different clinical entity and
is most common in children; 60%–80% of those
affected present with bilious vomiting in the 1st
month of life (6). However, as the use of CT in
emergency departments increases, midgut volvu-
lus is increasingly being recognized in adults.
Malrotation of the small bowel is the major
predisposing factor for midgut volvulus. In a mal-
rotation, there is abnormal ﬁ xation of the small
bowel mesentery, which results in an abnormally
short mesenteric root. This allows the small bowel
to twist around its mesentery, causing obstruction
and possibly ischemia of the bowel. Midgut volvu-
lus often occurs early in life, and in such cases sur-
gery is performed to repair the malrotation.
ever, volvulus also may occur in adulthood, and in
abdominal pain that resolves when the volvulus
spontaneously reduces. If it does not spontane-
ously reduce, patients at any age may present with
abdominal pain, nausea, and vomiting (1,7).
Conventional radiography usually yields non-
speciﬁ c ﬁ ndings and is rarely helpful in making a
diagnosis. On the other hand, ﬂ uoroscopic upper
GI and small-bowel examinations may reveal the
characteristic abnormal position of most of the
small bowel in the right abdomen and the resultant
abnormal location of the ligament of Treitz. These
are usually the preferred imaging tests when midgut
volvulus is suspected. On upper GI images, the liga-
ment of Treitz normally is located at or to the left of
the left L1 pedicle. In patients with malrotation, the
ligament of Treitz is abnormally positioned, usually
below and to the right of the left L1 pedicle. In the
presence of a midgut volvulus, the twisted segment
(usually a proximal segment) of small bowel has a
characteristic corkscrew-like appearance on ﬂ uoro-
scopic images (Fig 7) (6).
Ultrasonography (US) is sometimes helpful in
that an abnormal positional relationship between
the superior mesenteric vein and artery may be
appreciated, with the vein located to the left of
the artery, which is the opposite of its usual ori-
entation (6,8). However, US does not directly
show the abnormal position of the bowel and is
rarely used in this clinical setting.
Familiarity with the CT ﬁ ndings of midgut
volvulus is important, because many patients
present with nonspeciﬁ c symptoms and are ﬁ rst
evaluated with cross-sectional imaging. At CT,
a swirling of vessels in the mesenteric root may
be seen at the site of the volvulus (6,7,9). The
abnormal relationship between the superior mes-
enteric artery and vein, an ectopic location of the
majority of small bowel loops, and an abnormal
position of the ligament of Treitz (which was de-
scribed earlier) also may be seen (Fig 8).
image shows dilated cecum (arrow) in the left upper quadrant of the abdomen. The cecum is displacing
the contrast material–ﬁ lled 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.
are less common and also may predispose pa-
tients to cecal volvulus (1,10).
As opposed to volvulus in other locations,
colonic volvulus often has a characteristic ap-
pearance at conventional radiography, which may
be sufﬁ cient for a diagnosis in a large percentage
A dilated gas-ﬁ lled viscus, usually
located ectopically in the left upper quadrant or
mid abdomen, is a radiographic feature of cecal
volvulus. However, it is important to recognize
that the cecum may be displaced anywhere in the
abdomen (11). Proximal obstruction may or may
Cecal volvulus accounts for 25%–40% of all
cases of colonic volvulus. Congenital anomalies
of colonic ﬁ xation usually are present and include
an abnormal ﬁ xation of the right colon to the ret-
roperitoneum and abnormal motility of the right
colon. Factors that result in dilatation of the right
colon, such as pregnancy and recent colonoscopy,
old woman with abdominal pain. Ra-
diograph shows dilated air-ﬁ lled cecum
(arrow) in the left upper quadrant.
ﬂ uid-ﬁ lled 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).
Figure 11. Cecal volvulus. Contrast-
enhanced CT image shows dilated,
ﬂ uid- and gas-ﬁ lled cecum at the lower
midline. Pneumatosis of the cecum (ar-
rows) also is seen. The diagnosis was
conﬁ rmed at exploratory surgery.
patients with suspected cecal volvulus proceed
to CT if further imaging is required. At CT,
the abnormally positioned cecum often appears
in the upper mid and left abdomen and can be
traced back to the level of the volvulus, which
appears as an area of swirling of the bowel
and its mesentery, a ﬁ nding also known as the
“whirl” sign (Figs 11–16) (12).
Cecal bascule, ﬁ rst described in the early
1900s, refers to abnormal location of the dilated
cecum in the mid abdomen and results from up-
ward folding of the cecum on itself, without as-
sociated twisting. Cecal bascule occurs when the
cecum is loosely attached to its mesentery. Some
not be present, depending on the acuity of the
volvulus (Figs 9, 10) (1).
A diagnosis of cecal volvulus often is con-
ﬁ rmed with a contrast material enema study or
CT. During the enema, the distal colon usually
is decompressed, and there is a beaklike taper-
ing at the level of the volvulus. It usually is not
possible for much contrast material to pass
beyond the volvulus into the more dilated proxi-
mal colon and terminal ileum. For patients in
whom cecal volvulus is suspected on the basis of
radiographic ﬁ ndings, a contrast material enema
study may help conﬁ rm the diagnosis. However,
given the widespread availability of CT and the
relative speed with which it can be performed
compared with that of the enema study, most
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.
and a small-bowel obstruction. (b) Contrast-enhanced CT image shows displacement of the dilated ﬂ uid-
ﬁ lled cecum in the right upper quadrant (arrow), with resultant small-bowel obstruction.
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 ﬁ nding suggestive of pneuma-
tosis. The diagnosis of an infarcted cecal vol-
vulus was conﬁ rmed at exploratory surgery.
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.
have argued that cecal bascule is a form of cecal
adynamic ileus that may lead to perforation, de-
pending on duration of symptoms (13).
The transverse colon is the rarest site of colonic
<5%–10% of cases), but it is associated
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 ﬁ xation 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 of the colon at
the level of the twist. However, because volvulus
of the transverse colon is rare and not usually ex-
pected, the diagnosis is often made at CT, which
shows bowel obstruction and the classic mesen-
teric twist (Fig 17).
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
cause of large-bowel obstruction in the absence
of neoplasm and diverticular disease. However, in
developing countries, sigmoid volvulus causes a
majority of bowel obstructions and is presumably
caused by relatively high-ﬁ ber diets. It is also the
most common cause of bowel obstruction during
Because patients usually present with nonspe-
ciﬁ c abdominal pain and symptoms of obstruc-
tion, conventional radiography often is performed
as part of the initial work-up. Radiographic ﬁ nd-
ings that may be diagnostic of sigmoid volvulus
include a large air-ﬁ lled bowel loop, which rep-
The sigmoid is the most common site of colonic
volvulus and accounts for 60%–75% of all cases
of colonic volvulus. It is generally considered to
be an acquired condition because its prevalence
increases among those with chronic constipation
and sigmoid colonic redundancy due to a high-
ﬁ ber diet, pregnancy, hospitalization or institu-
tionalization, or Chagas disease (1,10,14). In de-
veloped countries, sigmoid volvulus is a common
52-year-old man with abdominal pain. Erect
radiograph shows the displacement of the sig-
moid colon (arrow) above the transverse colon
of the apex of the sigmoid colon cephalad to
the transverse colon on supine radiographs.
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 conﬁ rmed at endoscopy.
Figure 20. Sigmoid volvulus in a 46-year-old woman with abdominal pain. (a) Radiograph shows an
air-ﬁ lled, 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 conﬁ rm the diagnosis.
resents the sigmoid colon, arising from the pelvis
and extending cranially beyond the level of the
transverse colon (the “northern exposure” sign)
(Figs 18–23) (10,15). Other useful radiographic
features include the “coffee bean” sign, which re-
fers to the coffee bean–like shape that the dilated
sigmoid colon may assume (10,16). Similarly, the
“closed-loop” and “three-line” or “white-stripe”
ascending above the transverse colon. (b) CT image shows the site of the twist (arrow).
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).
shows the characteristic whirl sign at the level of the volvulus (arrow).
RG ■ Volume 29 • Number 5
Peterson et al 1293
3. Eisenberg R, Levine M. Miscellaneous abnormali-
ties of the stomach and duodenum. In: Gore RM,
Levine MS, eds. Textbook of gastrointestinal radiol-
ogy. 2nd ed. Philadelphia, Pa: Saunders, 2000; 675.
4. Godshall D, Mossallam U, Rosenbaum R. Gastric
volvulus: case report and review of the literature. J
Emerg Med 1999;17(5):837–840.
5. Menuck L. Plain ﬁ lm ﬁ ndings of gastric volvulus
herniating into the chest. AJR Am J Roentgenol
6. McAlister WH, Kronemer KA. Emergency gastro-
intestinal radiology of the newborn. Radiol Clin
North Am 1996;34(4):819–844.
7. Bernstein SM, Russ PD. Midgut volvulus: a rare
cause of acute abdomen in an adult patient. AJR
Am J Roentgenol 1998;171(3):639–641.
8. Shimanuki Y, Aihara T, Takano H, et al. Clockwise
whirlpool sign at color Doppler US: an objective
and deﬁ nite sign of midgut volvulus. Radiology
9. Fisher JK. Computed tomographic diagnosis of
volvulus in intestinal malrotation. Radiology 1981;
10. Ott DJ, Chen MY. Speciﬁ c acute colonic disorders.
Radiol Clin North Am 1994;32(5):871–884.
11. Freeny PC, Stevenson GW, eds. Margulis and
Burhenne’s alimentary tract radiology. 5th ed. St.
Louis, Mo: Mosby-Year Book, 1994; 362–365,
12. Frank AJ, Goffner LB, Fruauff AA, Losada RA.
Cecal volvulus: the CT whirl sign. Abdom Imaging
13. Fazel A, Verne GN. New solutions to an old prob-
lem: acute colonic pseudoobstruction. J Clin Gas-
14. Jones IT, Fazio VW. Colonic volvulus: etiology and
management. Dig Dis 1989;7(4):203–209.
15. Javors BR, Baker SR, Miller JA. The northern ex-
posure sign: a newly described ﬁ nding in sigmoid
volvulus. AJR Am J Roentgenol 1999;173(3):571–
Signiﬁ cant plain ﬁ lm ﬁ ndings in sigmoid volvulus.
Clin Radiol 1994;49(5):317–319.
17. Baker SR. The abdominal plain ﬁ lm. East Norwalk,
Conn: Appleton & Lange, 1990; 185–188.
signs describe the U-shaped closed-loop appear-
ance of the colon, which is dilated between the
two points of obstruction at the site of the volvu-
lus; and the obliquely oriented vertical white lines
that represent the opposed walls of the dilated
bowel loop (the center line) and the outer walls
of the bowel loop on either side (11,17).
In cases in which the diagnosis is uncertain,
a water-soluble contrast material enema study
or CT may be performed. In an enema study, a
beak-shaped area often is seen at the level of the
distal aspect of the twist in the sigmoid, beyond
which no contrast material passes. In addition to
providing diagnostic information, the enema may
help achieve reduction of the volvulus. At CT,
the abnormal position of the sigmoid colon and
swirling of the mesentery at the level of the volvu-
lus are visible. As with cases of volvulus involving
other sites in the GI tract, coronal and sagittal
reformations may be useful for locating the mes-
enteric swirl and evaluating the orientation of the
rotated bowel segment.
Volvulus may involve any portion of the GI tract
from the stomach to the colon and is an impor-
tant cause of acute or recurring abdominal pain.
Because a delay in diagnosis can have devastating
consequences, including bowel ischemia and in-
farction, prompt diagnosis is essential. The clini-
cal symptoms of volvulus often are nonspeciﬁ c,
and radiologists often are consulted for diagnos-
tic evaluations. This article describes the vari-
ous radiologic imaging appearances of volvulus
throughout the GI tract, emphasizing strategies
for achieving an accurate diagnosis.
1. Feldman M, Scharschmidt BF. Sleisenger and
Fordtran’s gastrointestinal and liver disease:
pathophysiology/diagnosis/management. 6th ed.
Philadelphia, Pa: Saunders, 1998; 324–328.
2. Yamada T, Alpers DH, Owyang C, Powell DW,
Silverstein FE, eds. Textbook of gastroenterology.
Philadelphia, Pa: Lippincott, 1991; 1404–1407.