Intrathoracic stomach rupture and possible volvulus

Case contributed by Dr Craig Hacking

Presentation

Abdominal pain, hypotensive and acidotic.

Patient Data

Age: 80-90
Gender: Female

The mediastinum is abnormal with multiple large rounded lucencies on the right side, displacing the heart to the left. Mild atelectasis and pleural effusion on the left at the base. Lucency in within the upper abdomen suggestive of pneumoperitoneum.

Conclusion

The mediastinal lucencies are not typical for pneumopericardium, rather pneumomediastinum. There is also a large hiatus hernia. Features are concerning for large hiatus hernia complicated by intrathoracic stomach perforation or volvulus. CT is recommended.

Poor renal function precluded the use of IV contrast.

The stomach appears entirely intrathoracic. There is gas and fluid surrounding this structure consistent with perforation and / or volvulus. Displacement of the mediastinum anteriorly and to the left with significant mass effect on the left atrium and to a lesser degree the right atrium. Small pericardial and pleural effusions. Minor dependant atelectasis.

Large volume intraperitoneal free gas. Moderate volume free fluid.

Within the limitations of a non-contrast study the liver, spleen, pancreas, right kidney and adrenal gland appear normal. Cholelithiasis. Simple cyst within the left kidney. Possible nodule associated with the left adrenal gland. Colonic diverticulosis without evidence of complication. Minor faecal loading. No evidence of bowel obstruction.

Heavily calcified vasculature.

Conclusion

  • The findings are most consistent with perforation of an intrathoracic stomach and / or gastric volvulus.
  • Surrounding free fluid and gas contributes to mediastinal displacement anteriorly into the left. Significant mass effect on the left atrium and to a lesser degree the right atrium.
  • Large volume intraperitoneal free gas and moderate volume free fluid.

Urgent surgical review is recommended.

Case Discussion

The patient was acidotic (pH 7.1) and had a lactate of 10 at the time of admission. The ED and surgical opinion was to treat the patient conservatively given the patient's age and comorbidities, under the palliative care physicians which the patient and her family agreed with. The patient passed away within 24 hours.

 

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Case information

rID: 41961
Case created: 30th Dec 2015
Last edited: 17th Sep 2016
Inclusion in quiz mode: Included

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