Tension gastrothorax: A rare cause of obstructive shock
Connor-Schuler R, and Debiane LG. Tension gastrothorax: A rare cause of obstructive shock. Crit Care Med 2019; 47(1).
Crit Care Med
Learning Objectives: Common etiologies of obstructive shock include cardiac tamponade, massive pulmonary embolism or tension pneumothorax. A tension gastrothorax is an extremely rare diagnosis and source of obstructive shock with gastric volvulus causing compression of mediastinal structures and subsequent hemodynamic instability. Diagnosis of this unusual condition is key as gastric decompression can reverse hemodynamic instability and can result in return of spontaneous circulation in cases of cardiac arrest. This case involves a patient who presented with obstructive shock requiring multiple vasopressors from a large paraesophageal hernia and gastric volvulus. Methods: 68-year-old male was initially admitted to the medical floor for cellulitis and acute kidney injury. On hospital day 6, however, he decompensated and was transferred to the medical ICU. He was hypotensive, tachycardic, and hypoxic. Patient was intubated on arrival, central and arterial lines were placed and vasopressors were initiated. Labs were consistent with multi-organ failure. Bedside echo revealed an ejection fraction of 70%, a dilated and non-collapsible IVC, and deviation of normal cardiac windows into the right chest cavity. Chest x-ray showed a large left sided hiatal hernia causing a tension effect and right shift of the mediastinum. Without significant clinical improvement despite preload optimization and gastric decompression from orogastric tube placement, the patient was emergently taken to the operating room where he was found to have a gastric volvulus with type IV paraesophageal hernia. Patient recovered and was eventually discharged to a rehabilitation facility. Results: Tension gastrothorax is an extremely rare cause of obstructive shock that can also present critically as mediastinal structures are compressed. Several case reports in the literature describe patients suffering cardiac arrest from tension gastrothorax with return of spontaneous circulation achieved following gastric decompression or reduction of abdominal contents by bedside thoracotomy. Our patient's hemodynamic instability resolved following surgical gastric decompression as well. Diagnosis has typically occurred by CT, however radiographs can display mediastinal shift, and echo can demonstrate cardiac shift, left ventricular diastolic collapse, or loops of bowel in the intrathoracic cavity. This case is unique as it demonstrates a rare cause of obstructive shock that is treatable even in the presence of profound hemodynamic instability.