Tension colothorax: a pleural effusion?

The need to suspect tension gastrothorax as a cause of obstructive shock in trauma care: A case report

INTRODUCTION

Traumatic tension gastrothorax is a type of obstructive shock similar to tension pneumothorax. However, tension gastrothorax is not well known among emergency physicians, and no consensus has yet been reached on management during initial trauma care. We present a case of traumatic tension gastrothorax in which tube thoracostomy was performed based solely on clinical findings very similar to tension pneumothorax, followed by emergency laparotomy.

PRESENTATION OF CASE

A 24-year-old male motorcyclist was brought to our emergency medical center after being struck by a motor vehicle. He was in respiratory failure and hypotensive shock with findings suggestive of pneumothorax. Although the physical findings were not fully in line with tension pneumothorax, we immediately performed finger thoracostomy. Subsequent radiography revealed left diaphragmatic rupture with hernia. After unsuccessful attempts to decompress the stomach with a nasogastric tube, immediate emergency laparotomy was performed. During the operation, the stomach, which had prolapsed through the ruptured diaphragm into the thoracic cavity, was manually returned to the abdominal cavity. The ruptured diaphragm was repaired with sutures.

DISCUSSION

Although distinguishing between tension pneumothorax and tension gastrothorax based on physical examination alone is difficult, tension gastrothorax requires careful attention to avoid intrapleural contamination from gastric injury. In addition, relying solely on stomach decompression with a nasogastric tube or delaying laparotomy could lead to cardiac arrest.

CONCLUSION

When tension pneumothorax is suspected during initial trauma care, tension gastrothorax should also be considered as a differential diagnosis and treated with immediate diaphragmatic repair once identified.

Mediastinal shift secondary to a diaphragmatic hernia: a life-threatening combination

An 85-year-old man was referred to our department, with a three-day history of increasing shortness of breath. Following clinical and radiological assessment, diaphragmatic herniation of bowel was identified to be causing mediastinal shift and respiratory distress. An emergency laparotomy identified a massive diaphragmatic defect which was not amenable to primary closure. A colopexy procedure was performed to comparmentalise the abdomen and obliterate the diaphragmatic defect. Despite aggressive treatment in the intensive care unit he died from multi-organ failure. This case highlights an extremely rare and life-threatening cause of mediastinal shift and respiratory distress.

Acute post-traumatic tension gastrothorax, a tension pneumothorax-like injury

Diaphragmatic rupture is an uncommon and frequently missed complication in blunt thoraco-abdominal trauma. Symptoms usually become apparent in a delayed phase, up to years after the trauma. An acute presentation is extremely rare and acute tension gastrothorax in which trapping of air in the intrathoracic stomach causes mediastinal shift and lung compression, as in tension pneumothorax, is exceptional. We only found two cases in the literature. We present here two other cases from our practice, with a review on the literature on post-traumatic diaphragmatic hernias.