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A 40 year old man is the unrestrained driver in a front-impact motor vehicle collision. He arrived with a respiratory rate of approximately 20/minute but haemodynamically normal. 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.
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