A 40 year old man is the unrestrained driver in a front-impact motor
vehicle collision. He arrives with a respiratory rate of approximately
20/minute but haemodynamically stable. Initial chest X-ray showed
an elevtaed and slightly thickened left hemidiaphragm, suggesting
a diaphragm injury. The patient was transferred, self-ventilating,
to the CT scanner. He gradually became more and more dyspneoic,
with rising respiratory rate.
CTs show a left hemithorax almost
full of the stomach, with shift of mediastinal structures to the
right. Towards the end of the scan the patient became progressively
tachycardic and then hypotensive at 80/60. Further scanning was
terminated and the patient anaesthetised, intubated and ventilated.
Positive pressure ventilation caused re-expansion of the left lung
and partial return of the stomach into the abdomen.
The patient was transferred to the
operating room for laparotomy, which identified a large circumferential
laceration of the diaphragm approximately 2cm from the costal margin.
The stomach and spleen were reduced into the abdomen and the diaphragm
injury repaired primarily.
Tension gastrothorax has previously
been described. In the spontaneously ventilating patient the negative
pressure generated in the thoracic cavity progressively sucks
the stomach into the chest with each breath. Eventually, respiratory
and haemodynamic compromise ensue, as with a classic tension pneumothorax.
Various methods have been used
to treat the condition acutely. Nasogastric trubes can be placed
to decompress the stomach - although placement may be difficult
due to kinking at the level of the diaphragm. Needle decompression
of the stomach has also been suggested but this may theoretically
lead to contamination of the thoracic cavity. Positive pressure
ventilation allows immediate re-expansion of the lung and forces
intraperitoneal contents back into the abdomen. As the patient
will require operative repair, ventilation is already indicated.
Burton JH. Intrathoracic stomach presenting as acute tension
gastrothorax. Am J Emerg Med 1999;17:370-1
Tension gastrothorax complicating acute traumatic diaphragmatic
rupture. J Emerg Med 1992;10:25-30
Acute gastric distension: a lesson
from the classics. Hospital Medicine Volume
62 Number 3
trauma.org (8:2) February 2003