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Case Report A 72-year-old man was transferred to our emergency department with sigmoid volvulus (Fig. 1A). He had had repeated episodes of abdominal pain for several years. His condition had always been labeled subocclusive crisis and had resolved spontaneously or with conservative treatment. Evaluation of two abdominal radiographs during follow-up revealed, to our surprise, a shift of the hepatic shadow from the right to the left upper quadrant. The time elapsed between the radiographs was 24 hours (Figs. 1B and 1C). The second radiograph was obtained immediately after the patient awakened. He usually slept in the left lateral decubitus position. One day later, abdominal CT (Figs. 1D–1G) performed in both lateral decubitus positions confirmed considerable mobility of the liver in the transverse plane. When the patient was lying in the left lateral decubitus position, the liver rotated clockwise and occupied the entire left hypochondrium. Images with the patient in the right lateral decubitus position showed the liver shifting to its normal anatomic position. No other organ misplacement, intestinal malrotation, or other anomaly was noticed. The patient did not report discomfort while undergoing imaging or after staying in the left lateral decubitus position for several hours.

We correlated the amount of gastric fluid identified by sonography in 143 fasting patients with the presence of duodenal ulcer disease and gastric-outlet obstruction as seen on barium studies. Unselected consecutive patients who were referred for a barium study of the upper gastrointestinal tract were included in a double-blinded prospective study. Sonograms were obtained in the right lateral decubitus position to allow gastric fluid to accumulate in the antrum, where it was quantified by measuring the maximal cross-sectional area of antral fluid in square centimeters. Sonograms revealed no fluid or a small amount (less than 5 cm2) in 87 (61%) of the patients and a large amount of fluid (greater than or equal to 5 cm2) in 56 patients (39%). Barium examinations showed a duodenal ulcer in 26 (46%) of the 56 patients with sonographic evidence of a large amount of gastric fluid compared with 10 patients (11%) in the group with little or no fluid on sonography (p = .001). Sonographic evidence of a large amount of fluid was found in all five patients who had gastric-outlet obstruction on barium examination (p = .02). The detection of a large amount of fluid in the stomach on sonography appears to be a feature of duodenal ulcer disease and gastric-outlet obstruction.