INTRODUCTION: Signet ring cell carcinoma (SRCC) is an uncommon and poorly-differentiated tumor. It arises mostly in the gastrointestinal tract. Its incidence has increased in past few years. Volvulus is the twisting of bowel around its mesentery. It is relatively common in cecum and sigmoid colon and rare in other parts of gastrointestinal tract. It is usually primary in nature but can be secondary to tumors, diverticulosis, pregnancy, or others. Herein, we present a case of advanced gastric SRCC with peritoneal carcinomatosis presenting initially as a secondary small bowel volvulus (SBV) without appreciated gastric mass on imaging. We believe our case is unique due to rarity of such presentation. CASE DESCRIPTION/METHODS: An 80-year-old male presented for abdominal fullness, early satiety, weight loss, and excessive flatulence and postprandial vomiting with gastric outlet obstruction-like symptoms for three weeks. Computed tomography scan of abdomen (CT) showed a jejunal volvulus. The patient was treated conservatively. Repeat CT of abdomen showed resolution of the SBV. Magnetic resonance enterography of the abdomen and pelvis showed duodenum distension of 3.4 cm, however proximal jejunum never appeared fluid distended and a jejunal obstructing process could not be excluded. No gastric lesions or thickening was appreciated on all imaging. Deep Enteroscopy revealed antral circumferential mucosal thickening with mucosal changes under white light and Narrow Band Imaging suggestive of carcinoma. Dilated duodenum with transition area and obstructed proximal jejunum were noted with no intrinsic lesion or mucosal abnormalities. Biopsy from gastric mucosa revealed gastric adenocarcinoma, signet ring cell type. Diagnostic laparoscopy revealed peritoneal implants throughout abdominal cavity. A large, hard, and fixed mass was found in the distal stomach causing tethering of proximal jejunum. Side to side loop duodenojejunostomy and partial omentectomy were done, gastrojejunostomy was not possible. Pathology from right upper quadrant peritoneal implant, peritoneal biopsy, and omentum was consistent with metastatic adenocarcinoma from primary gastric site. Palliative chemotherapy and palliative trans-pyloric duodenal stent were performed. DISCUSSION: To the best of our knowledge, this is the first case of gastric SRCC presenting as intermittent SBV without noted tumor on imaging. In such a presentation of SBV with no notable tumor on imaging, high suspicion of a primary gastrointestinal tumor should be always considered.Figure 1.: Computed tomography scan of the abdomen (CT) showing a jejunal volvulus (A). Repeat CT of the abdomen without contrast showed dilation of proximal small bowel up to 4.2 cm with a transition point at the superior mesenteric artery take-off, no small bowel volvulus was seen (B).Figure 2.: Enteroscopy showing hard consistency in the prepyloric region and antrum (A), and diffuse circumferential nodularity of the gastric mucosa with ulcerations and irregular margins (B).