Tension gastrothorax

Case contributed by Dr Jayanth Keshavamurthy

Presentation

Status post robotic hiatal hernia repair. Desaturation to 84%. Left sided back pain.

Patient Data

Age: 65 years
Gender: Female
X-ray

Chest x-ray

Large area of lucency occupying most of the left hemithorax, with sparing of the apex. Airspace opacification in right lower zone.

Is this a tension pneumothorax? What should you do next? What should you not do?

X-ray

Follow up chest x-rays

See individual descriptions for each chest x-ray below.

CT

CT thorax

  • Acute herniation of the gas- and fluid-distended fundus and body of the stomach into the left chest without evidence for volvulus or gastric ischaemia.
  • Associated compressive atelectasis left lower lobe and lingular segments left upper lobe, trace left pneumothorax and trace pleural fluid. Left chest tube in good position with small subcutaneous emphysema.
  • Moderate simple right pleural effusion and small to moderate dependent atelectasis. Possible trace pneumothorax extreme right base.
  • Mesh appears to bulge through the gastro-oesophageal junction.
  • Nasogastric tube terminates in the distal oesophagus, likely obstructed at the gastro-oesophageal junction by the herniated stomach.
X-ray

Post-operative chest x-ray

Finally repeat surgery and the stomach was brought back down into the abdomen, successfully.

Case Discussion

This is a rare complication of hiatus hernia surgery where the entire stomach migrated into the thorax and confused the clinical team who thought it was pneumothorax. Chest tubes did not work. OGD and NG tube placement confirmed the intrathoracic location of the stomach. 

See also reference 4 below, well-written similar case report.

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Case information

rID: 50945
Case created: 29th Jan 2017
Last edited: 8th Aug 2017
Inclusion in quiz mode: Included
Institution: Augusta University

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