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

Chest x-ray

X-ray

Large area of lucency occupying most of the left hemithorax, with sparing of the apex. Airspace opacification in right lower zone. Acute intrathoracic left-sided gastric herniation, misdiagnosed as a pneumothorax.

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

Follow up chest x-rays

X-ray

Frontal: a left apical pleural pigtail catheter placed with no benefit.

Frontal : pigtail catheter removed and large bore chest tube is tried, also with no benefit.

Frontal: Dobhoff feeding tube is tried, curving towards the lucency in the left hemithorax.

Frontal: endoscopic guidance of enteric tube into stomach - x-ray shows that the lucency is in fact the stomach and not a pneumothorax.

CT thorax

CT
  • Acute herniation of the gas- and fluid-distended fundus and body of the stomach into the left chest without evidence for volvulus or gastric ischemia.
  • 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-esophageal junction.
  • Nasogastric tube terminates in the distal esophagus, likely obstructed at the gastro-esophageal junction by the herniated stomach.

Post-operative chest x-ray

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. EGD 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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