INTRODUCTION:A 60 year old white man was transferred from a medicine ward to Medical Intensive Care Unit (MICU) because of acute respiratory distress, marked anxiety, tachycardia (pulse 158), and increased blood pressure to 213/103. These events occurred three days after laparoscopic placement of a jejunostomy feeding tube under general anesthesia followed by attempts to initate feedings. A portable chest x-ray revealed marked over-aeration of the left hemithorax, with no lung markings, and mediastinal shift to the right. There was no pleural line visible. The patient had a life-long history of mental retardation and kyphoscoliosis. Prior chest x-rays revealed thoracic deformity and elevation of the left hemidiaphragm. A para-esophageal hernia was recognized but the risk of surgical correction was considered prohibitive at that time.
CASE PRESENTATION:His recent medical history consisted of a lengthy hospital stay in MICU for pneumonia and respiratory failure. He received a tracheostomy for inability to wean from mechanical ventilation despite multiple trials; however, he was successfully weaned after tracheostomy. Laparoscopic jejunostomy was performed three days earlier to allow removal of a nasoduodenal feeding tube. Mechanical ventilation was resumed on arrival to ICU with some stabilization. Vital signs on morning rounds while sedated on the ventilator were: Pulse 130, Blood pressure 130/70, respiratory rate 15, temperature 36.8 C. Arterial blood gases revealed mild to moderate respiratory acidosis. Breath sounds were absent in the left chest. The left chest and abdomen were tympanitic on percussion. The on-call surgical resident had recommended placement of a thoracostomy tube for a suspected pneumothorax. The patient remained tachycardic but maintained blood pressure. Tube feedings were stopped. An emergency chest CT scan was obtained which revealed marked distention of the stomach and proximal small bowel, with near complete occupation of the left hemithorax. See scout film Figure 2. There was extensive retained gastric fluid as well. Due to extreme distention, and difficulty with prior attempts to place a nasogastric tube, the Gastroenterology service was consulted to perform urgent endoscopy for the purpose of decompressing the stomach. A gastric decompression tube was then inserted under direct vision. These interventions resulted in improvement in vital signs with gradual return to baseline. Revision of the jejunostomy feeding tube was performed. Use of the jejunostomy tube was successfully instituted several days later.
DISCUSSIONS:The present case represents a rare example of gastrothorax with respiratory distress simulating tension pneumothorax resulting from mechanical ileus in the presence of a paraesophageal hernia. The patient’s congenital and acquired deformities undoubtedly contributed to his morbidity. The complications of paraesophageal hernia include incarceration with gastrointestinal obstruction, bleeding and perforation. Respiratory compromise may result from aspiration, abscess, and increased gastric volume as in this case.
CONCLUSION:Tension gastrothorax is usually a complication of total intrathoracic stomach. Emergency thoracocentesis or tube thoracostomy for this condition are contraindicated due to risk of complications such as bowel perforation, sepsis, empyema, acute lung injury and respiratory failure. The preferred inital treatment, as in this case, is gastric decompression. Clinicians should consider the diagnosis of gastrothorax in situations of respiratory compromise in patients with congenital abnormalities, as in this case, prior to attempting a thoracostomy placement, which would likely lead to adverse outcomes.
DISCLOSURE:Joyce Gonzales, None.