Tension Gastrothorax and Hemodynamic Collapse due to Gastric Outlet Obstruction in a Paraesophageal Hernia

Excerpt

A 70-year-old woman with a longstanding large paraesophageal hernia (PEH) was initially seen in surgical clinic with complaints of dyspnea, decreased appetite, and 100 lb. weight loss over the course of 2 years. Surgical repair was declined by the patient. Several months later, she presented to our emergency department with acute onset left chest and flank pain accompanied by severe shortness of breath, anorexia, and multiple episodes of non-bloody, non-bilious emesis. On exam, she was hemodynamically unstable and in respiratory distress with heart rate 120 beats per minute, blood pressure 70/50 mmHg, and respiratory rate > 40 breaths per minute. She was pale and diaphoretic. Breath sounds were absent on the left side; heart sounds were diminished and best appreciated over the right chest. Her abdomen was soft, but tender to palpation in the left upper quadrant. Extremities were cool and mottled with thready distal pulses. Volume resuscitation with IV fluids and vasopressors were rapidly initiated. Abnormal laboratory tests at presentation included WBC 16 K/uL, lactate 4.5 mmol/L, and NT-proBNP 1188 pg/mL. Admission chest x-ray (CXR) showed elevation of the left hemidiaphragm, near-complete opacification of the left hemithorax, and significant mediastinal shift to the right with rightward cardiac displacement and reduced aeration of the right lung (Fig. 1). A bedside cardiac ultrasound showed right ventricular diastolic collapse consistent with tamponade physiology. A computed tomography scan of the chest, abdomen, and pelvis with IV contrast demonstrated a markedly distended and completely intrathoracic stomach (Fig. 2a), with displacement of the antrum above the gastroesophageal junction consistent with gastric volvulus (Fig. 2b). A nasogastric tube (NGT) was placed with rapid evacuation of > 1000 cc blood-tinged gastric contents. At this point, the patient’s hypotension resolved almost immediately, pressors were discontinued, and her shortness of breath markedly improved. She was taken to the operating room for (i) esophagogastroduodenoscopy, showing healthy mucosa with evacuation of an additional 1.9 L gastric contents; and (ii) laparoscopic reduction of a combined mesenteroaxial and organoaxial gastric volvulus, reduction of incarcerated colon, omentum, and mesentery, and anterior gastropexy with placement of a percutaneous endoscopic gastrostomy (PEG) tube. She recovered well and was discharged on postoperative day no. 4. She will return in 2–3 months for completion of PEH repair.

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