Acute atraumatic peri-arrest tension gastrothorax presenting to the emergency department

Abstract

A 71-year-old woman was brought in by ambulance to the emergency department with sudden-onset difficulty in breathing whilst shopping at a large UK retail shopping centre. She had no respiratory history and portable chest X-ray revealed a huge gastrothorax, secondary pneumothorax and mediastinal shift. Clinical deterioration with haemodynamic instability required urgent decompression. Successful needle decompression followed by tube thoracostomy improved patient condition with no further complications. Surgical repair was performed but was delayed by COVID-19. This case provides a rare presentation of an acute life-threatening tension gastrothorax with difficult management considerations. A review of the management options is undertaken.

Background

Tension gastrothorax is a rare complication of hiatus hernia and is predominantly associated with paediatric congenital diaphragmatic herniation, post-upper-gastrointestinal surgery or in the context of trauma with diaphragmatic rupture.^{1 2} It is estimated that only 0.3% of hiatus hernias are complicated by tension gastrothorax.³ Diagnosis relies on a high clinical suspicion of these factors and based on a history of abdominal pain with signs/symptoms of tension pneumothorax.⁴ The acute near-fatal presentation of this case to the emergency department (ED) provided a diagnostic and management dilemma, with accurate image interpretation required. The minimal patient history available in this case highlights the importance for clinicians of having a high clinical suspicion and an awareness of the key features of this diagnosis on a plain radiograph. Emergency gastric decompression with nasogastric (NG) tube insertion may be difficult due to kinking at the level of the diaphragm and chest decompression is fraught with complications.^{5 6} In contrast to other cases within the literature, a positive outcome was seen using emergency needle decompression and tube thoracostomy with future elective surgery planned.^{5 7}

Case presentation

A 71-year-old woman was brought in by ambulance from a large UK retail centre in acute respiratory distress. Paramedic handover reported sudden-onset difficulty in breathing (DIB) whilst shopping with fluctuating drowsiness in the ambulance. The patient was unable to complete words when talking and therefore incapable of providing a detailed history of the events. She reported no chest or abdominal pain. There was no history of trauma or surgery. Due to hospital restrictions as a result of COVID-19, no family members were in attendance for further collateral history.

Arrival observations read: SaO₂ 90% 6L O₂, respiratory rate 48 breaths/min, heart rate 135 BPM, blood pressure 190/129 mm Hg, temperature 36.7°C and Glasgow Coma Scale (GCS) score 15.

Medical history included hypertension treated with ramipril and no underlying respiratory history. She had no smoking history and lived independently with her husband. Retrospectively, she reports a 10-year history of intermittent epigastric pain and vomiting after food. She had no history of trauma or surgery preceding the onset of symptoms.

Chest auscultation illicited air entry with coarse crepitations bilaterally. Normal heart sounds were heard. Abdomen was soft non-tender. No limb swelling or signs of deep vein thrombosis were present.

Immediate treatment of high-flow oxygen, intravenous broad-spectrum antibiotics and slow intravenous infusion of saline 0.9% was commenced. Arterial blood gas (ABG) was performed. Urgent portable chest X-ray was performed.

Patient condition deteriorated with increasing drowsiness and confusion (GCS 13). The patient’s breathing became increasingly laboured with signs of fatigue setting in. ABG revealed a type-2 respiratory failure.

Investigations

Arrival ABG (6L O₂ with paramedics): pH 7.275, pCO₂ 8.03 kPa, pO₂ 11.38 kPa, HCO₃ 27.4 mmol/L, base excess −0.8 mmol/L, lactate 2.57 mmol/L.

ECG: Left axis deviation, sinus tachycardia at 135 BPM.

Arrival chest X-ray (portable) can be viewed in figure 1. Subsequent chest X-ray following treatment with chest drain is displayed in figures 2 and 3.

Figure 1.

Portable chest X-ray performed in the resus department at arrival.

Figure 2.

Portable chest X-ray performed in the resus department following chest drain insertion illustrates change in appearance of lung markings across the right lung field.

Figure 3.

Contrast study chest X-ray performed on day 3 of admission.

Cross-sectional imaging can be seen in videos 1–3 and display the extent of the pathology.

Video 1.

Download video file ^{(2.1MB, mp4)}

DOI: 10.1136/bcr-2020-240478.video01

Video 2.

Download video file ^{(9.1MB, mp4)}

DOI: 10.1136/bcr-2020-240478.video02

Video 3.

Download video file ^{(1.8MB, mp4)}

DOI: 10.1136/bcr-2020-240478.video03

CT report (admission): There is atelectasis and consolidation of the right lower lobe, right upper posterior segment and left lower lobe medial segment which appears secondary to mass effect from a large hiatus hernia. The rest of the left lower lobe, lingula and left upper lobe are aerated.2.5 cm foci of ground-glass in the right upper lobe anterior segment. Further subpleural ground-glass is also seen anterior to the left oblique fissure in the left upper lobe apical segment. No bronchiectasis, pleural effusion. Left basal linear atelectasis is noted. There is a small pneumothorax with chest drain in situ, between the right fourth and fifth ribs laterally, projecting superiorly towards the apex. A single drain aperture lies adjacent to the pneumothorax posteriorly (axial series two image 34). There is a huge hiatus hernia with all of the stomach above the level of the diaphragm. The stomach is distended and contains a mixture of gas and gastric contents. Furthermore, the transverse colon lies within the hernia. On limited series, there is no evidence of obstruction or perforation. Within the spleen, there is a 3 cm hypoenhancing focus with average Hounsfield of 24 with peripheral calcification which is in keeping with splenic cyst. The liver remains below the diaphragm.

CT report (repeat on day 2): A large hiatus hernia is again seen. The entire stomach and much of the transverse colon in the chest. The stomach has undergone organoaxial volvulus. No evidence of gastric obstruction, inflammatory change or perforation. Loops of small bowel and the left colon in the abdominal cavity are not dilated and not thick walled. There is no free air or free fluid in the peritoneal cavity. No focal liver lesions. There is a calcified low-attenuation lesion in the spleen in keeping with a haemangioma. The pancreas and adrenal glands are normal. Both kidneys enhance normally. A degenerative scoliosis is present in the lumbar spine. Right hip replacement is in situ. Both lungs are now fully inflated. The right chest drain remains in a good position anterior to the right upper lobe of the lung.

Differential diagnosis

At initial presentation, management was commenced for chest sepsis based on the history of DIB coupled with the low SaO₂, tachycardia, drowsiness and crepitations. This was by no means a typical presentation characterised by a sudden onset of symptoms whilst ambulating at a retail shopping centre. Medical history and clinical findings did not lead to a suspicion of asthma/COPD. Acute flash pulmonary oedema was considered within the differentials, but no clinical signs of heart failure were present.

Prior to CXR, the absence of pleuritic chest pain and the examination findings did not point to a diagnosis of pneumothorax. Following CXR, consideration was made for diaphragmatic rupture, but in the absence of trauma it was felt unlikely. It was believed a large hiatus hernia could be seen but lung markings were absent in the remaining lung field. Shifting of the mediastinum and patient deterioration warranted therapeutic needle aspiration followed by tube decompression which offered an improved patient condition.

After stabilisation, urgent portable CXR revealed lung markings within the right lung field where they previously had been absent. Cross-sectional CT imaging was performed which revealed the whole stomach and part of the transverse colon within the thorax as outlined within the CT report. The stomach contained a mixture of gas and gastric contents. Secondary right-sided pneumothorax was present. The stomach was distended but no complete obstruction present.

Treatment

High-flow oxygen and chest sepsis management was commenced at arrival. Needle thoracostomy followed by drain thoracostomy was performed within the ED. NG tube was inserted to decompress the stomach following patient stabilisation and cross-sectional imaging. Chest drain was removed following in-patient observation. Out-patient upper-gastrointestinal surgery was performed successfully.

Outcome and follow-up

The patient remained stable as an in-patient for 2 weeks with no further respiratory compromise. Contrast studies showed no gastrointestinal injury was sustained during emergency management. Chest drain remained in situ for 4 days while an in-patient under the care of the respiratory physicians and removed with no further complication. NG tube was removed during hospital stay with no further short-term complication. Follow-up CT scanning showed no gastric outflow obstruction. Nine months following admission, no further acute events or respiratory symptoms had occurred. Symptoms of hiatus hernia were ongoing with attacks intermittently after food approximately once weekly. Surgery was significantly delayed due to COVID-19 but was completed successfully at a later date.

Discussion

The majority of published cases of tension gastrothorax in the adult population are in the context of diaphragmatic rupture secondary to trauma or as a complication of recent upper-GI surgery. Right-sided gastrothorax is minimally previously reported and this has been in the context of trauma.⁸ Variance is seen in management within the literature and is most likely due to differing severity of patient condition and variable clinician recognition/understanding of this pathology. Preferable management involves gastric decompression with nasogastric tube insertion. It may be difficult to pass a NG tube past the level of the diaphragm due to the tension effect and patient deterioration has been provoked by subsequent hyperventilation with further gastric dilatation.⁵ If patient condition allows, successful endoscopic gastric decompression is a suitable option.⁹ If haemodynamically unstable or unable to decompress the stomach, emergency management with needle decompression followed by surgical tube thoracostomy is required to prevent/treat cardiac arrest.^{10 11} Complication rates are high and risks of such management include bowel perforation, faecothorax, acute lung injury, empyema and sepsis.^12–14

This case is rare for a number of reasons: acuity, patient age, right laterality, no trauma, no recent surgery and the absence of collateral history. Furthermore, secondary pneumothorax is believed to be present on arrival CXR and seen improved on later imaging. In this case, due to haemodynamic instability and the CXR findings of absent lung markings, needle decompression followed by tube thoracostomy was performed with a subsequent improvement in patient condition. A lack of clinician understanding of tension gastrothorax within the department meant that gastric decompression was not attempted as an initial strategy but further highlights the importance of the understanding of this condition. Interpretation of the key radiological features is imperative and includes a large air-filled lucent structure within one of the lung fields, mediastinal shift, absent gastric bubble and a fluid level within the lung field.^{15 16} Subsequent review of the literature has highlighted a proposed management algorithm in Bunya et al.⁷

Subsequent cross-sectional imaging displayed the diaphragm to be intact and it is still unclear of the true timeline of events in this case. It is believed that the large intrathoracic pressure effect led to secondary pneumothorax which resulted in the sudden patient deterioration while shopping and aligns with published cases within the literature.¹⁷

Learning points.

• Signs and symptoms of tension pneumothorax with associated abdominal pain require consideration for a diagnosis of tension gastrothorax.

• Plain radiograph features of tension gastrothorax include a large air-filled lucent structure within one of the lung fields, mediastinal shift, absent gastric bubble and a fluid level within the lung field.

• Management involves nasogastric tube insertion or endoscopic gastric decompression. If haemodynamically unstable, then chest decompression with blunt tube thoracostomy is required but is high risk for complications.