How to manage tension gastrothorax: a case report of tension gastrothorax with multiple trauma due to traumatic diaphragmatic rupture

Abstract

BackgroundTension gastrothorax is a kind of obstructive shock with prolapse and distention of the stomach into the thoracic cavity. Progressive gastric distension leads to mediastinal shift, reduced venous return, decreased cardiac output, and ultimately cardiac arrest. Therefore, it is crucial to decompress the stomach distension for the initial resuscitation of tension gastrothorax.Case presentationA 75-year-old female was transported to our resuscitation bay due to motor vehicle crash. At the time of arrival to our hospital, the patient developed cardiac arrest. While undergoing cardiopulmonary resuscitation, an unstable pelvic ring was recognized, so we performed a resuscitative thoracotomy to control hemorrhage and to perform direct cardiac massage. Once we performed the thoracotomy, the stomach and omentum prolapsed out of the thoracotomy site and through the diaphragm rupture site and spontaneous circulation was recovered. Neither the descending aorta nor the heart was collapsed. Although we had continued the treatment for severe pelvic fracture (including blood transufusions), the patient died. Given that (1) the stomach prolapsed out of the body at the time of the thoracotomy; (2) at the same timing, spontaneous circulation returned; and (3) the descending aorta and heart did not collapse, we hypothesized that the main cause of the initial cardiac arrest was tension gastrothorax.ConclusionsRecognition of tension gastrothorax pathophysiology, which is a form of obstructive shock, makes it possible to manage this injury correctly.

Non-traumatic Tension Gastrothorax: A Potential Mimicker of Tension Pneumothorax

“…The presence of a diaphragmatic defect serves as a prerequisite for the condition and thus, cases are typically seen in the pediatric population with congenital diaphragmatic defects or later in life with acquired defects, most commonly in the setting of trauma. However, cases involving enlarging hiatal hernias as well as secondary to post-surgical complications have also been reported [4][5][6][7][8]. While the incidence of congenital diaphragmatic hernia is approximately 1 per 2,500-5000 live births, true tension gastrothorax is exceedingly rare and possesses a slight female predominance.…”

“…forces the stomach into the thorax through the diaphragmatic defect. Accumulation of gastric contents such as air, fluid, or food into the abnormally positioned and angulated gastroesophageal junction functions as a one-way valve, leading to increased intrathoracic pressure [2][3][4].…”

“…Several key radiographic features are useful for distinguishing a gastrothorax from a tension pneumothorax. These include: lack of the normally seen gastric bubble, poorly defined left hemidiaphragm (which is typically inferiorly displaced and readily identified in cases of tension pneumothorax), and/or the presence of an air-fluid level within the left hemithorax [2,4]. The diagnosis of tension gastrothorax is best evaluated on cross-sectional imaging such as CT with identification of communication between the distal-most portion of the intrathoracic stomach and bowel.…”

“…Once the diagnosis of tension gastrothorax has been made, prompt decompression of the stomach via nasogastric tube is the recommended initial treatment followed by definitive surgical repair of the diaphragmatic defect, once stabilized [4]. If recognized and treated early, the prognosis is excellent, with complete return to baseline in most instances.…”

Life threatening nontraumatic tension gastrothorax

“…Common etiologies include congenital diaphragmatic hernia occurring in childhood or adulthood and traumatic diaphragmatic injury (blunt or penetrating trauma) . Immediate clinical and radiographic evaluation should lead to accurate diagnosis followed by emergency decompression of the stomach before laparotomy with reduction in herniated viscera and repair of the diaphragmatic defect . An uneventful recovery can be expected postintervention.…”