An Uncommon Cause of Respiratory Distress: Ruptured Tension Gastrothorax

A gastrothorax occurs when the stomach becomes displaced into the thoracic cavity. Rarely, this gastrothorax can rupture, which can lead to respiratory distress, hemodynamic compromise, and cardiac arrest. Here, we discuss the case of a 69-year-old male who presented to the emergency department (ED) for evaluation of generalized weakness and shortness of breath without associated upper respiratory symptoms. On physical exam, the patient was hemodynamically unstable with absent lung sounds on the left. A portable chest X-ray (CXR) was obtained, which initially revealed concern for tension hydropneumothorax. A chest tube was placed, which drained a large amount of bilious fluid and stabilized the patient. CT imaging revealed a large diaphragmatic hernia with herniation of the stomach into the left hemithorax and a chest tube coursing lateral to and above the stomach. The patient was taken emergently to the operating room, where a large area of necrosis was noted about the greater curvature of the stomach with ischemic perforation. The patient underwent partial gastrectomy and primary diaphragmatic hernia repair and recovered despite a complicated hospital course. Ruptured gastrothorax is rare and presents similarly to other causes of tension physiology. Clinicians should consider CT imaging in stable patients when diaphragmatic hernia or ruptured gastrothorax is possible, and should consider placing a chest tube above the level of the stomach if they suspect this diagnosis by history and CXR in an unstable patient.