Gastric perforation through a hiatus hernia into the left lung in an 84-year-old woman

Abstract

An 84-year-old woman presented to the emergency department with a sudden onset of chest pain, shortness of breath and vomiting. She had a medical history of hiatus hernia, gastro-oesophgeal reflux disease and asthma only, but had several recent courses of oral steroids to treat her asthma. Initially she was hypoxic, tachycardic and normotensive. ECG was normal, chest X-ray showed a hiatus hernia and right middle zone consolidation. Inflammatory markers were normal. CT angiogram was performed to exclude aortic pathology, for which it was negative. It did however show a large hiatus hernia which had perforated and was communicating with the left lung. The patient deteriorated clinically and became hypotensive and more hypoxic. She was transferred to the intensive care unit but died 36 hours later as she was too unwell to undergo any exploratory surgery.

Background

Pleuritic chest pain with shortness of breath is a common acute presentation in emergency departments. This case demonstrates a very rare but severe pathology causing these symptoms that may not normally be considered.

Case presentation

An 84-year-old woman was brought into the emergency department by ambulance. She complained of a 2-hour history of sudden onset, severe left sided chest pain accompanied by dyspnoea. The pain started shortly after eating her evening meal and was associated with vomiting. The pain was sharp and pleuritic in nature and radiated into her back. There was no cough or haemoptysis. The patient had been well previous to this episode but had recently finished a course of oral steroids for an exacerbation of asthma.

On initial examination, she was afebrile, tachycardic at 115 beats/min, blood pressure was 100/65, oxygen saturations were 89% on room air and she was tachypnoeic at 26 breaths per minute. She appeared to be in severe pain.

Cardiovascular examination revealed normal heart sounds with no radio-radial or radio-femoral delay. Initial lung sounds were normal with equal air entry and no added sounds. Her abdomen was soft, non-tender and non-distended.

The patient’s medical history was of asthma, a hiatus hernia, gastro-oesophgeal reflux disease and fibroids. Her regular medications were salbutamol and seretide inhalers only.

She lived alone and was a retired hospital doctor.

Investigations

Twelve lead ECG was normal with no ischaemic changes. Venous blood showed a normal full blood count, liver function, renal function, electrolytes and C reactive protein. An arterial blood gas with a Fio₂ of 24% revealed a mild type 1 respiratory failure, metabolic alkalosis and lactate of 2.0 (pH 7.485, PO₂ 13.2, Pco₂ 4.28, HCO₃ ^- 25.6, base excess 1.4).

Chest and abdominal radiographs were performed 30 min after arrival. Chest radiography (figure 1) revealed a large hiatus hernia and patchy left mid-zone consolidation, though not in keeping with a typical lobar pneumonia. There was no subdiaphragmatic free air. Abdominal radiography was normal.

Figure 1.

Chest X-ray showing hiatus hernia with air–fluid level.

A CT angiogram of the aorta and pulmonary vasculature was performed 90 min after arrival to assess for aortic dissection or pulmonary embolism (figure 2). It was negative for both of these. However, it demonstrated significant patchy consolidation in the left lung. It also demonstrated a large hiatus hernia containing most of the stomach. There was a communication from the stomach into the area of consolidation and a pneumomediastinum was seen beneath the aortic arch (figure 3).

Figure 2.

Axial CT angiogram showing stomach (A), heart (B), gastro-pulmonary fistula (C) and pulmonary consolidation (D).

Figure 3.

Axial CT angiogram showing pneumomediastinum below the aortic arch (A).

Endoscopy was performed which did not show a clear perforation.

Differential diagnosis

Perforation of stomach in hiatus hernia, pulmonary haemorrhage, atypical pneumonia.

Treatment

Following the CT scan the patient began to deteriorate. Her blood pressure, which was initially maintained with modest intravenous fluid resuscitation, was 70/40 with a heart rate of 120 beats/min. Three hours after initial presentation, her oxygen saturations also fell to 78% on high flow oxygen. While she had not before, she now required respiratory and circulatory support and was referred to the intensive care team. They reviewed and began managing her in the emergency department.

She was treated for any lung infection with intravenous meropenem and gentamicin. She also received omeprazole 40 mg intravenously.

She was referred to the intensive care team who started vasopression with metraminol and OptiFlow respiratory support. They also inserted an arterial line and central venous catheter. Despite this, she remained unstable and had to be intubated and ventilated. She also received maximal doses of norepinephrine for blood pressure support.

Concurrently, she was referred to the local general surgery team as well as those at a tertiary centre that also had thoracic surgeons on site. Due to the continued deterioration in her condition, and following discussion by all teams involved, it was decided to proceed to endoscopy in the first instance with a view to consider operative intervention once the patient was more stable. This endoscopy was undiagnostic.

Outcome and follow-up

She remained on the intensive care unit where she remained intubated and ventilated. Intravenous antibiotics were continued and vasopressin (0.03 U/min) and norepinephrine (up to 1 mL/hour). Despite this, her urine output continued to decrease and her blood lactate level continued to increase. Discussions were held with her next of kin and the decision was made that operative intervention would not be in her best interest. This decision was consistent with wishes expressed by the patient shortly before intubation. Care was withdrawn and she died 36 hours after her initial presentation.

Discussion

While both hiatus herniae and abdominal visceral perforations are relatively common, there are very few reports of perforation of the stomach into the thoracic cavity. There is one reported case of a perforation into the mediastinum which presented with acute abdominal pain and was treated with an omental patch.¹ A further case is described by Rahr et al of an acute on chronic presentation of abdominal and interscapular pain caused by a perforated gastric ulcer in a hiatus hernia.² A report by Shafii et al details a case where gastric perforation into the thorax was confirmed by post mortem examination.³ Similarly, to the case we describe, the patient demonstrated a rapid clinic deterioration from the time of presentation. There have also been two reported cases of perforation of a para-oesophgeal hernia into the left ventricle, causing catastrophic bleeding in one patient⁴ and death in another.⁵ Parker and Sabanathan report a case of an incarcerated hiatus hernia perforating in a 72-year-old, treated with oesophagectomy.⁶

While this is a rare pathology, patients present to the emergency department complaining of pleuritic chest pain and shortness of breath much more commonly and 3%–6% of patients presenting to the emergency department have chest pain as their main complaint.⁷

A recent review proposed a ‘Big Five’ life threatening diagnoses to rapidly investigate in the emergency room: acute coronary syndrome, acute pulmonary embolism, acute aortic syndrome, tension pneumothorax and Boerhaave syndrome.⁸ Initial assessment of these conditions includes history and physical examination followed by 12 lead ECG, chest and abdominal X-rays and blood tests. Early angiography and CT will aid assessment of an aortic dissection. CT angiogram, including pulmonary angiography, was performed in this case, primarily to rule out an acute aortic syndrome or pulmonary embolism. However, as discussed above it was also invaluable in revealing the definitive diagnosis.

Oral corticosteroids are a common treatment for acute exacerbation of asthma in adults. The British Thoracic Society recommends a dose of 40–50 mg of prednisolone (or parenteral equivalent) for at least 5 days.⁹ However, oral steroid use is also associated with gastrointestinal side effects. When compared with placebo, a recent systematic review found a 43% increased risk of gastrointestinal bleeding or perforation in those taking oral steroids.¹⁰ The patient presented in this care reported several courses of oral steroids in the months prior to their acute presentation.

Previous similar cases^{1 2 6} were treated successfully with various surgical procedures. However, as in this case, the condition was fatal in others.^3–5 Where the patient survived, there was less rapid haemodynamic or respiratory decline, allowing treatment of a more stable patient.

This was a complex case that also highlights the importance of marrying clinical presentation to investigation results. This is demonstrated by the routine reporting of the chest radiograph the following day by a consultant radiologist. It was reported as pneumonia due to the consolidation that can also be seen on the CT images. However the clinician would expect a gradual onset of shortness of breath, malaise, purulent cough with raised inflammatory markers. All of these were not present in this case, leading the clinicians to consider alternative diagnoses. Maintaining this approach is important, especially for clinicians in the emergency department.

Learning points.

• Acute assessment of chest pain in the emergency department should be systematic to allow early diagnosis of common and less common pathologies.

• Sudden onset pleuritic chest pain, with shortness of breath and vomiting can rarely represent gastric perforation from a hiatus hernia into the thoracic cavity.

• Rapid diagnosis and identification of this diagnosis is necessary as the patient can become unstable very quickly, making definitive treatment impossible.