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We have carefully read the interesting article recently published in your journal about a giant sigmoid diverticulum. In our institution we have diagnosed two similar cases and we would like to contribute our casuistry.

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Purpose: To depict the characteristics of a special type of gastric volvulus caused by acute re-herniation of a previous hiatal hernia.Materials and methods: We present the case of a male patient with known history of a giant hiatal hernia who presented to our emergency department with a chief complaint of epigastric pain, oral intolerance and incoercible vomiting in the last 24 h. On suspicion of abdominal complication, an emergent computed tomography (CT) scan was performed.Results: Gastric volvulus secondary to downward re-herniation of the fundus into the abdominal cavity was the cause of this patient's symptoms. This mechanism, which was demonstrated by comparing the CT findings of the acute episode with previous imaging studies, reveals a largely unrecognized pathogenic mechanism of gastric volvulus.Conclusions: Acute gastric volvulus should be suspected in patients with hiatal hernia. CT allows its diagnosis and likely underlying pathophysiological mechanism.

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BACKGROUND: Gastric volvulus (GV) is a life-threatening emergency condition that prompts emergent surgical management. With the advent of high-resolution computed tomography (CT), the role of radiologists in its diagnosis has become essential. Although many cases of GV have been described in the literature, its pathophysiology is still poorly understood. In addition, there is substantial terminological confusion with associated entities such as paraesophageal hernia, upside-down stomach, organo-axial or chronic GV. METHODS: We conducted a retrospective review of clinical, radiological findings and other relevant data for seven patients with previous radiological diagnoses of a large hiatus hernia who presented with acute GV to the emergency department of our institution. We report data on age, sex, medical history, clinical presentation, imaging, treatment and outcomes for each case. RESULTS: The CT findings at acute presentation showed the antrum lying above the diaphragm and dilated fundus below the diaphragm. By comparing the position of the stomach at acute presentation with previous imaging examinations, we confirmed a hypothesis put forward by a few authors decades ago that re-herniation of the gastric fundus into the abdomen is a common pathophysiologic trigger leading to acute GV. This hypothesis has not been supported by modern imaging examinations. CONCLUSIONS: We have provided imaging evidence supporting that the pathophysiology of many GVs is based on caudal re-descent of hiatal hernia into the abdominal cavity. Given the terminological disparity used in the literature in this context, we believe it appropriate to introduce and extend the term 'back-and-forth stomach' to refer to this type of GV.

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La fascitis necrotizante es una infección agresiva y altamente destructiva de la fascia y el músculo con una alta morbimortalidad. Se suele presentar en pacientes inmunocomprometidos tales como VIH, diabéticos, oncológicos o trasplantados, siendo sus localizaciones más habituales las extremidades, pared abdominal y periné; en esta última localización recibe el nombre de gangrena de Fournier. Su asociación con úlceras de decúbito es infrecuente, relacionándose en la mayoría de las ocasiones con procesos osteomielíticos, traumatismos con heridas cutáneas o presencia de cuerpos extraños. Presentamos un caso clínico de un paciente con fascitis necrotizante secundaria a úlcera de decúbito. Nos parece interesante presentar las características clínicas, así como exponer los hallazgos radiológicos de esta entidad y, por otra parte, acentuar la importancia de un adecuado cuidado de las úlceras por presión, ya que pueden ser el origen de la fascitis necrotizante

Necrotizing fasciitis is an aggressive and highly destructive infection of the fasciae and muscles with high morbidity and mortality. It usually occurs in immunocompromised patients such as HIV, diabetic, oncology or transplant patients. Its most common locations are the extremities, abdominal wall and perineum; in this latter location it is called Fournier's gangrene. Its association with pressure ulcers is infrequent, being connected in most cases with osteomyelitic processes, traumas with skin wounds or presence of foreign bodies. We present the clinical case of a patient with necrotizing fasciitis secondary to pressure ulcer. We find it interesting to present the clinical characteristics as well as the radiological findings of this entity and, on the other hand, to emphasize the importance of an adequate care of pressure ulcers, since they can be the origin of necrotizing fasciitis

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