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Home > Articles > Tension Gastrothorax

Karim Brohi
London, England

Case Presentation
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.

Discussion

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.

References

Tadler SC, Burton JH. Intrathoracic stomach presenting as acute tension gastrothorax. Am J Emerg Med 1999;17:370-1

Slater RG. 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

Comments

drmohsinraza, February 01, 2008

After Compliments
A good case presentation
When the rupture of left diaphragm is diagnosed with a plain Xray and the laparotomy is going to be performed as emergency,Is there any necessity to send the patient to CT scan
I have recently presented a report of 62 cases of Rupture of Diaphragm in International Surgical Update in collaboration with RoyalCollege of Surgeons Edin at Muscat Oman.I reported 24 cases of Rupture of left diaphragm that we diagnosed with initial Plain roengenogram and CT done in these cases did not add any more informations .
I am presenting “Rupture of Diaphragm——a Diagnostic dilemma “at Qatar Emegency Conference in Feb 2008
Dr Mohsin Raza
Khoula Hospital
Tertiary Trauma Centre
Muscat, Oman
Sultanate of Omaemail address
email;
.(JavaScript must be enabled to view this email address)

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