Survival case of acute and severe respiratory distress due to spontaneous tension gastrothorax

Abstract

A 20-year-old woman presented with abdominal pain and shortness of breath. She was in obstructive shock with absent breath sounds on the left haemithorax. Chest X-ray showed a large radiolucent shadow with absent lung markings and mediastinal shift to the right side with concerns for tension pneumothorax. Though tube thoracostomy was done on the left side of the chest, column movement was absent. To confirm the diagnosis CT with contrast was done that revealed a huge left side diaphragmatic defect with abdominal contents in the thorax and mediastinal structures are shifted to left. She underwent emergency laparotomy and postoperative period was uneventful.

Background

Tension gastrothorax is a rare and life-threatening condition of obstructive shock that radiologically mimics tension pneumothorax.¹ Ordog et al reported the first description of tension gastrothorax.² Gastrothorax develops when the stomach herniates through an acquired or congenital defect in the diaphragm and leads to progressive mediastinal shift.³ This leads to respiratory failure, obstructive shock and cardiac arrest, much like a tension pneumothorax.⁴

In the literature over the last two decades, there are only eight reported cases of tension gastrothorax with cardiac arrest with uneventful recovery.⁵ In our case, the patient had a better survival outcome following cardiac arrest. Delayed recognition of tension gastrothorax will lead to a detrimental outcome. So it is imperative that emergency physicians should know the clinical presentation and management of the rare and life-threatening cause of obstructive shock.⁴ We are reporting a case of an acute and severe life-threatening cause of respiratory distress that leads to cardiac arrest and finally diagnosed to have tension gastrothorax.

Case presentation

A 20-year-old woman presented to the emergency department with abdominal pain and breathlessness for the last 2 hours. On admission, the patient was in distress and could not speak in complete sentences. She had severe pain in the epigastric region that was sudden in onset, rapidly progressing, sharp pain which is radiating to back associate with severe dyspnoea. The vital signs at presentation were: blood pressure 90/60 mm Hg, heart rate 150/min, respiratory frequency 30/min and oxygen saturation 89% in ambient air, and she was apyretic. On physical examination, there were no cyanosis or any visible marks of trauma. She had reduced breath sounds on the left haemithorax with the tracheal shift to the right side. On abdominal examination, there was tenderness with guarding on the epigastric region. Otherwise, the systemic examination was normal.

Investigations

Portable chest radiography revealed a large radiolucent shadow on the left side and suspected to have a pneumothorax (figure 1). Tube thoracostomy (TT) of size 28 F was inserted on the left side of chest and connected to underwater seal, but column movement was absent, and she did not show any improvement in haemodynamic status. Chest X-ray following the insertion showed that the tube is in position (figure 2). Lung Ultrasound revealed absent lung sliding (video 1). CT with contrast was done to rule out of the cause of absent lung sliding and revealed that stomach, duodenum and omentum have slid into the thorax through a left side diaphragmatic defect and mediastinal structures are shifted to left (figure 3).

Figure 1.

Portable chest radiograph shows large radiolucent shadow (arrow) with absent stomach bubbles, poorly defined left hemidiaphragm on the left side (arrowhead) and shift of the mediastinum to the right side (double arrow).

Figure 2.

Portable chest radiograph after insertion of intercostal drainage tube on left side (arrow) that curves down in the thoracic cavity and persistent mediastinal shift to the left side (double arrow).

Video 1.

Download video file ^{(943.1KB, mp4)}

DOI: 10.1136/bcr-2020-235281.video01

Figure 3.

CTof the chest and abdomen with intravenous contrast. Axial (A) and coronal (B) CT images show that the stomach (arrow), duodenum and omentum have slid into the left thoracic cavity through a left side diaphragmatic defect. It causes a shift of the mediastinum to the left side (double arrow) and compresses the mediastinal structures and the left lung (the patient was in obstructive shock).

Differential diagnosis

The most common causes of obstructive shock include pericardial tamponade, tension pneumothorax and acute pulmonary embolism was included in the differential diagnosis. Point-of-care ultrasound and ECG helped in ruling out pericardial tamponade and acute pulmonary embolism. (figure 4). However, tension pneumothorax was still a differential diagnosis until the CT was done.

Figure 4.

The ECG shows sinus tachycardia

Treatment

Oxygen was administered via 60% venturi at 10 L/ min. Intravenous fluids were given to improve blood pressure. Systemic intravenous opioids were given as analgesic to improve the pain. Tube thoracotomy was planned. Prior to intercostal drainage tube insertion, the patient went into the cardiac arrest. The cause of cardiac arrest was due to obstructive shock leading to hypotension, hypoxia and aciodosis. She was intubated and resuscitated. Return of Spontaneous Circulation (ROSC) has been obtained after three cycles of cardiopulmonary resuscitation (CPR) as per Advanced Cardiac Life Support (ACLS) guidelines. Simultaneously, a 28 Fr silicone chest tube was inserted on the left side in the fifth intercostal space in the midaxillary line and connected to an underwater seal. Eventually, she was connected to a mechanical ventilator. Nevertheless, column movement was absent and she did not show any improvement in haemodynamic status. We reassessed the pateint and checked for Displacement of tube, Obstruction of tube, Pneumothorax, Equipment failure (DOPE) to find out any cause for hypoxia. Nevertheless, we could not find a reason for the absent column movement. Chest X-ray following post intercostal drain (ICD) insertion showed that the tube is in position. Further evaluation with CT showed evidence of gastrothorax. She underwent emergency laparotomy where the visceral organs had been reduced back into the intraperitoneal cavity, and diaphragmatic rent was repaired.

Outcome and follow-up

The patient was under observation in the intensive care unit. Postoperative chest X-ray showed expansion of the left lung and mediastinal shift had improved. The postoperative course was uneventful. The patient got discharged on the 15th postoperative day. After discharge, she was asymptomatic.

Discussion

Obstructive shock constitutes 2% among different kinds of shock.⁶ The most common causes of obstructive shock include pericardial tamponade, tension pneumothorax and acute pulmonary embolism.⁷ Tension gastrothorax is an unusual life-threatening cause of obstructive shock that pose a diagnostic dilemma and can be mistaken for tension pneumothorax.⁸ Tension gastrothorax describes mediastinal shift by distended intrathoracic stomach herniated through a congenital or acquired diaphragmatic defect.^{3 4 8} The clinical picture of tension gastrothorax with acute respiratory distress and reduced or absent breath sounds in the left haemithorax in an otherwise healthy adult has commonly been mistaken for a tension pneumothorax and managed as such leading to increased morbidity and mortality.^{3 9} Immediate clinical and radiographic evaluation leads to accurate diagnosis and should be followed by emergency decompression of the stomach before laparotomy with reduction of herniated viscera and repair of the diaphragmatic defect.

In several reports of tension gastrothorax, diaphragmatic defects have been notified to be seen three times more on left side following blunt and penetrating traumas in 3%–5% and 10%–15%, respectively.¹⁰ The frequency of spontaneous diaphragmatic rupture is <1% of all diaphragm injuries,¹¹ with median age being 40 years.¹² A review of literature by Losanoff et al found that coughing was the preceding event in 9 (32%) patients, physical exercise in 6 (21%), vaginal delivery in 4 (14%), vomiting in 2 (7%) and massage in 1 (4%). There were 5 (18%) patients in whom no effort preceded the hernia.¹² In the index case, there was no history of trauma or former surgical intervention. Our patient had a recent history of acute gastroenteritis—vomiting and diarrhoea, 2 weeks prior to presentation. That could possibly have been preceding event, following which the rupture occurred. The acuity of presentation in our case could have been due to herniation of abdominal contents through the ruptured diaphragm leading to the pain and respiratory distress. As an emergency physician, being the first contact of cases, clinical suspicion is significant in the diagnosis of such a rare entity. Clinically, tension pneumothorax is a good mimicker of the tension gastrothorax and present similarly with a clinical picture such as breathlessness, hypotension following compression to mediastinal vessels tachycardia and absent breath sounds on the left haemithorax. In delayed presentation, they present with progressing pain, respiratory distress and vomiting or in cardiopulmonary arrest due to significant mediastinal compression and acute venous return failure.¹³ In our case, the clinical presentation and findings were in accordance with the literature.

The initial resuscitation of tension gastrothorax is to resolve obstructive shock by decompressing the distending stomach. The following procedures have been described to decompress tension gastrothorax:

1. Insertion of a nasogastric tube (NGT).

2. Needle thoracostomy (NT) or TT.

3. Emergency surgical decompression (thoracotomy or laparotomy).

Emergency insertion of an NGT is life-saving and recommended in the initial resuscitation, but it is difficult or impossible to place due to the anatomical change of the gastro-oesophageal junction.^{3 14} However, in the index case, NGT was inserted without any difficulty and could find out the tip in chest X-ray. Though it helped to decompress the stomach, it did not improve the haemodynamics as the patient was in extremis.

NT or TT has been tried several times, considering tension pneumothorax as a common differential diagnosis. However, they do not have high success rates. Care must be taken not to injure the stomach wall because the distended stomach might be adjacent to the parietal pleura. Some authors suggest gastric decompression by transthoracic needle aspiration to gain time for surgery and obtain clinical stability.¹⁵ Finally, the optimal choice of treatment is emergency surgery, and it decreases morbidity and mortality.^{10 16}

For surgical treatment, thoracotomy, laparotomy or both may be performed. Both thoracotomy and laparotomy allow resolution of obstructive shock.^{16 17} With a laparotomy, the surgeon can explore other abdominal organ injuries. Abdominal organ reduction and primary diaphragmatic repair are performed.

Patient’s perspective.

When I brought my wife to the Emergency Department, she was in a lot of abdominal pain, which had started just couple of hours ago. She was never sick previously, but this time, she had intolerable pain. She was immediately attended to, but soon, I could see that she had become unconscious and the doctors had started giving her chest compressions. I was very scared about losing her. Though the doctors could get her heart beating, she was still not out of danger. They shifted her to scan and told me that scan shows her stomach has come up to the chest, and hence she could not breath and needed immediate surgery. After taking high-risk consent, they operated her immediately. It was not over here. She still required multiple surgeries; she lost lot of weight, developed infection of chest. However, with determination and support of family and hospital staff, slowly and steadily, she has improved. Doctors said that this is a very rare condition. I am very grateful that my wife had the strength to recover from jaws of death and be back with us.

Learning points.

• The emergency physician should be aware of the clinical presentation of rare events like tension gastrothorax, though obstructive shock constitutes only 2% of the shock.

• The radiographic findings in X-ray, such as lack of stomach bubble in the left upper quadrant and poorly defined hemidiaphragm, will give a clue to tension gastrothorax, which was present in our case.

• Absent lung sliding with bar code sign in point-of-care ultrasound after the placement of intercostal drainage prompted us to evaluate further with CT and eventually helped in the successful resuscitation of the patient.

• Tension gastrothorax could represent an additional ‘T’ in 5Ts of reversible causes of cardiac arrest.

• In the Bedside Lung Ultrasound in Emergencies (BLUE) protocol, tension gastrothorax could represent another cause for absent lung sliding.