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INTRODUCTION

Bochdalek’s hernia (BH) with abdominalviscera is rare in adults and acute tensiongastrothorax as its complication is unusual. Dueto rare occurrence, prompt diagnosis of acutetension gastrothorax is difficult particularlywhen clinical and radiographic features mimica tension pneumothorax or hydropneumothoraxleading to management errors.1 Acute gastricvolvulus is most often reported among thoseaged over 60 years and paraoesophageal herniais the most frequently associated diaphragmaticdefect.2 We report rare occurrence of acutetension gastrothorax and BH in an young maleinitially misdiagnosed as left hydropneumo-thorax.

CASE REPORT

A 21-year-old previously healthy male wasreferred as a case of left sided hydropneumo-thorax from a local hospital. He had suddenonset epigastric pain and breathlessness of 2

days duration. The pain was severe andradiating to back. Nausea and frequentunproductive retching were associated. Patientwas refusing to eat due to aggrevation of painand was unable to walk even few yards due topain and breathlessness. There was nosignificant medical or surgical history exceptfor intermittent upper abdominal pain since twomonths. He was not a tobacco smoker oralcohol drinker. On physical examination,patient was thin built, mildly dehydrated butwas haemodynamically stable. Respiratorysystem examination showed bulging ofhemithorax, decreased breathsounds andsuccussion splash on left side. Abdomen wasscaphoid with tenderness in the epigastric area.Total leucocyte count was 15,100/mm3 with86% polymorphonuclear leucocytes. Bloodbiochemistry was normal. Human immuno-deficiency virus (HIV) serology tested negative.A postero-anterior (PA) chest radiograph(Figure 1) showed air and fluid in the left

Case Report:Acute tension gastrothorax in an adult

K. Gowrinath,1 M. Gayatri,2 G. Varaprasada Rao3

Departments of 1Pulmonary Medicine, 2Radiology and Imaging sciences,3Surgical Gastroenterology, Apollo Speciality Hospital, Nellore

ABSTRACTTension gastrothorax is a rare life threatening condition and may occur as an unusual complication of Bochdalek’shernia (BH) in an adult. We report the rare occurrence of acute tension gastrothorax in a 21-year-old male with BH.The tension gastrothorax was due to acute organo-axial volvulus and the diagnosis was established by the computedtomography (CT) of chest. The risk of misdiagnosis is high when air and fluid in the dilated stomach simulateshydropneumothorax clinically and is interpreted through postero-anterior chest radiograph alone. In our case,percutaneous fine needle aspiration of fluid within the dilated stomach facilitated nasogastric tube insertiondecompressing the stomach and allowed surgery to be done electively.

Key words: Gastrothorax, Bochdalek’s hernia, Volvulus, HydropneumothoraxGowrinath K, Gayatri M,Varaprasada Rao G. Acute tension gastrothorax in an adult. J Clin Sci Res 2017;6:241-4; DOI:http://dx.doi.org/10.15380/2277-5706.JCSR.17.10.002.

Online accesshttp://svimstpt.ap.nic.in/jcsr/oct-dec17_files/

2cr.17.10.002.pdfDOI: http://dx.doi.org/10.15380/2277-5706.JCSR.17.10.002

Corresponding author: Dr K. Gowrinath,Senior consultant, Department of PulmonaryMedicine, Apollo Speciality Hospital,Nellore, India.e-mail: drgowrinathk@hotmail.com

Received: September 19, 2017, Accepted: September 30, 2017.

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hemithorax with shift of mediastinum toopposite side. Nasogastric tube could not bepassed. Percutaneous needle (20 Gauge)aspiration yielded 1400 ml of thin whitish fluidand patient felt better. Later nasogastric tube

Figure 1: Chest radiograph showing (postero-anteriorview) air and fluid in the left hemithorax with shift ofmediastinum to opposite side

Figure 2: The chest CT scanogram showing nasogastrictube within the stomach in the left hemithorax

Figure 3: Sections of CT scan of chest showing organo-axial volvulus of stomach and oral contrast filledstomach in the left hemithorax

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could be inserted and the gastric contentsaspirated with further symptomaticimprovement. Sections of CT of chest withcontrast (Figures 2, 3 and 4) showedorganoaxial volvulus of stomach and other

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uneventful recovery and post-operative PAchest radiograph (Figure 5) showed re-expanded left lung and was discharged after 5days. Patient is currently doing well during thefollow up period of 14 months.

DISCUSSION

Tension gastrothorax may result fromcongenital or acquired (Iatrogenic or traumatic)diaphragmatic defects. Abnormal rotation(More than 180 degrees) of stomach is unusualand difficult as its position is firmly secured bythe gastrophrenic ligaments, oesophagealhiatus, retroperitoneal fixat ion of theduodenum, short gastric vessels and gastrocolicligaments. In congenital diaphragmatic hernia,these gastric attachments are lax or absentincreasing the risk of volvulus.3 Our patient hadall three features of acute gastric volvulusoriginally described by Borchardt (Borchardt’striad) like frequent unproductive retching,severe and constant abdominal pain anddifficulty or inability to insert a nasogastrictube.4 Multi-slice CT of chest with coronal andsagittal images is the most useful imagingtechnique and in selected cases, magneticresonance imaging may be required.5 In ourcase, CT of chest with different reconstructed

Figure 5: PA chest radiograph showing re-expandedlung and normally placed hemidiaphragm on left side

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Figure 4: Sections of CT scan of chest showing stomachand other herniated organs (Spleen, pancreas,transversecolon with splenic flexure and descending colon) of BHalong with posterior defect in the left hemidiaphragm

herniated organs (spleen,pancreas,transversecolon with splenic flexure and descendingcolon) of left sided BH along with a large defectof approximately 6 cm in the lefthemidiaphragm. Upper gastrointestinalendoscopy revealed grossly distended stomachwith plenty of food residue. Pylorus wasdeformed and duodenum was normal. After twodays, patient underwent elective surgerythrough laparotomy approach. On inspection,stomach did not have ischemic changes anddetorsion of the volvulus was done followedby removal of adhesions between lefthemidiaphragm and spleen, reduction of theherniated contents, closure of the diaphragmaticdefect and anterior gastropexy. Patient made

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sections was diagnostic of gastric volvulus andBH along with contents. Prompt diagnosisfollowed by surgery is essential as gastricischemia, perforation and acute haemorrhage,pancreatic necrosis and omental avulsion arethe potential life threatening complications ofgastric volvulus.6 In a similar case before, chesttube was inserted after succussion splash washeard and PA chest radiograph findingssimulated hydropneumothorax in a 25 year-old-male who presented with respiratory distressand upper abdominal pain.7 In gastrothorax,tube thoracostomy for emergency relief maylead to complications such as bowelperforation, sepsis, faecothorax, empyema,acute lung injury and respiratory failure.8

Percutaneous needle thoracostomy wasrecommended as a safer, quicker and welltolerated procedure without causing spillage ofstomach contents.9 We did percutaneous fineneedle thoracostomy without any complicationbefore the diagnosis of gastrothorax was made.

In tension gastrothorax, insertion of anasogastric or orogastric tube is the initialprocedure of choice as it can relieve gastriccompression and also visible through imagingstudy establishing the location of stomach.10 Inour case, nasogastric tube was visible duringchest CT study (Figure 2) confirminggastrothorax. The surgical treatment ofgastrothorax due to acute gastric volvulus andBH include detorsion of the volvulus, reductionof the herniated contents, closure of thediaphragmatic defect and fixation of thestomach to the anterior abdominal wall. Oursurgical approach was through laparotomy butwith laparoscopic technique, even BHcomplicated with gastric volvulus can bedischarged within 2 days of emergencysurgery.11

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