Upside-down stomach as a rare cause of obstructive shock and cardiac arrest

Excerpt

A 60-year-old woman was admitted to our intensive care unit because of haemodynamic instability seemingly caused by wound infection after surgical fixation of a fractured L5 vertebra. She suffered from severe rheumatic polyarthritis and spondylosis, and had a history of multiple spine interventions. Additionally, hiatal hernia with gastroesophageal reflux was known and complicated by postoperative subileus. On the ICU, blood pressure had to be supported by norepinephrine, and metabolic acidosis was present. Central venous blood pressure was elevated and volume administration only tolerated poorly. Although the acoustic window was limited, focussed transthoracic echocardiography excluded right heart failure. The left ventricle appeared hypovolaemic with kissing papillary muscles (Fig. 1a) and contracted hyperdynamically (supplementary videos 1). The left atrium seemed to be compressed externally by an echo-intense structure (Fig. 1b, c, supplementary videos 2 and 3). Subsequent computer tomography confirmed an extensive air-filled upside-down stomach obstructing the left atrium (Fig. 1d–f). After “air” drainage via a gastric tube the haemodynamics improved immediately. One month later on the peripheral ward, the patient had to be resuscitated, presenting with the same clinical symptoms. Due to recurrent gastric tube decompression resuscitation was successful and surgical fundoplication was performed consecutively. In conclusion, an upside-down stomach represents a rare condition of obstructive shock and cardiac arrest. After initial tube decompression physicians should seek operative revision.

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