[ Chest Imaging and Pathology for Clinicians ]

An Unusual Source of Tension

Patrick J. Sylvester, MD; Akshay B. Vijayaraman, MD; and Carleen R. Spitzer, MD

CASE PRESENTATION: A 67-year-old man with a history of hypertension, type 2 diabetes, and
COPD requiring supplemental oxygen at baseline (4 L by nasal cannula) was admitted to the
hospital for progressive dyspnea and dysphagia in the context of a newly diagnosed supra-
glottic mass. CHEST 2022; 162(2):e93-e97

KEY WORDS: Chest radiograph; diaphragmatic injury; gastrothrax; hernia; tension physiology

The patient had reported a nearly 100-pound weight
loss over the course of the prior year as well as
progressive dysphagia for both solids and liquids. A
CT scan of the neck, completed as part of an
outpatient workup, revealed a supraglottic lesion that
appeared to involve the epiglottis. CT scan of the
chest obtained for staging purposes showed
emphysema, several left-sided rib fractures, and
herniation of portions of the abdominal contents
through the lateral aspect of the left hemidiaphragm.
Of note, the patient had disclosed a remote injury,
before his recent illness, that had reportedly resulted
in multiple broken ribs without other known
complications. The patient had been referred as an
outpatient to our institution’s ear, nose, and throat
program for the supraglottic lesion. Unfortunately,
before this evaluation he had presented to a local ED
with acute dyspnea and was subsequently transferred
to our institution for expedited workup. Ear, nose,
and throat was consulted on admission, and flexible
nasopharyngolaryngoscopy was performed, which
showed a large epiglottic mass with narrowing of the
supraglottic and glottic airway.
On hospital day 2, the patient underwent uncomplicated
awake tracheostomy with subsequent direct laryngoscopy
with biopsy of the mass and well as
esophagogastroduodenoscopy (EGD) with placement of a
small-bore feeding tube. He was returned to the hospital
ward while awaiting pathology with tentative plans for
total laryngectomy. On postoperative day 1, the patient
reported abdominal discomfort. A portable abdominal
radiograph was obtained, which showed a nonobstructive
bowel gas pattern as well as a left-sided diaphragmatic
hernia that was stable compared with a prior CT scan of
the chest. Given his ongoing pain, a CT scan of the
abdomen/pelvis with enteral and IV contrast was
obtained, which was concerning for enlargement of the
diaphragmatic hernia with distension of the intrathoracic
stomach concerning for obstruction. General surgery was
consulted and had tentatively planned for a semi-urgent
endoscopy, diaphragm repair, and gastrostomy tube
placement. Manual aspiration of the small-bore
nasointestinal tube was attempted; however, the patient’s
condition worsened acutely with the development of
tachycardia, tachypnea, hypoxemia, and hypotension. A
chest radiograph was obtained (Fig 1).

AFFILIATIONS: From The Ohio State University Wexner Medical Copyright Ó 2022 American College of Chest Physicians. Published by
Center, Columbus, OH. Elsevier Inc. All rights reserved.
CORRESPONDENCE TO: Patrick J. Sylvester, MD; email: Patrick.Sylvester@ DOI: https://doi.org/10.1016/j.chest.2022.02.009
osumc.edu

chestjournal.org e93
Figure 1 – Portable chest radiograph showing herniation of the stomach
within the left hemithorax (gastrothorax) with compressive atelectasis of
the left lower lobe. Contralateral shift of the mediastinum is observed
(solid arrow). Additionally seen are fractures of the 7th, 8th, and 9th ribs
(empty arrows).

What is the diagnosis?

e94 Chest Imaging and Pathology for Clinicians [ 162#2 CHEST AUGUST 2022 ]

Diagnosis: Tension gastrothorax
Discussion
Clinical Discussion
In the context of his significant work of breathing, the
patient was placed on mechanical ventilation via his
tracheostomy. Additional attempts to manually aspirate
air from the existing small-bore enteric tube were
unsuccessful. At the time, the caliber of the enteric tube
may have been insufficient for large-volume aspiration
and was likewise incompatible with the use of low
intermittent suction. Later review of previous CT
imaging showed that the tip of this enteric tube was
located below the diaphragmatic defect, further limiting
its utility in decompression of the intrathoracic portion
of the stomach (Fig 2).
The patient’s condition continued to decline, with
worsening tachycardia, tachypnea, and hypotension.
Serum lactate was notably elevated to 4.0 mM. The
patient was subsequently taken emergently to the
operating room. During upper endoscopy, the
endoscope was advanced into the incarcerated,
intrathoracic portion of the stomach. This showed a
distended stomach with pale gastric mucosa consistent
with mild ischemic changes. As the stomach was
endoscopically decompressed and subsequently
retracted from the intrathoracic cavity, the surgical and
Figure 2 – Coronal reconstruction of chest CT scan obtained after tra-
cheostomy, EGD, and nasointestinal tube placement. Herniation of the
stomach across a left diaphragmatic defect (empty arrow). A small-bore
nasointestinal tube is seen with its tip terminating in the intra-
abdominal portion of the stomach below the diaphragm (solid arrow).
EGD ¼ esophagogastroduodenoscopy.
chestjournal.org
anesthesia teams noted significant reduction in heart
rate and increase in BP. The defect of the left diaphragm
was repaired laparoscopically, and a gastrostomy tube
was placed. The patient was returned to the ICU and
was able to be weaned off vasopressors and mechanical
ventilation. A postoperative radiograph showed
improved aeration of the left hemithorax (Fig 3).
Radiologic Discussion
Tension gastrothorax is an uncommon diagnosis,
characterized by significant herniation of the stomach
and potentially other intraabdominal contents through a
diaphragmatic defect. As was seen in this case, a chest
radiograph (Fig 1) can suggest this diagnosis by the
presence of a circumscribed air-fluid level within the left
hemithorax consistent with the gastric bubble, as opposed
to its usual location below the left hemidiaphragm.1 In
this case, the presence of mass effect within the left
hemithorax is suggested based on compressive atelectasis
seen in the left lower lobe. Likewise, the mediastinum is
notably shifted to the patient’s right, which can be seen by
the carina and central airways, which are appreciable
right of the midline spinous processes. Also visible in this
radiograph are fractures of the posterolateral portions of
the left seventh, eighth, and ninth ribs related to the
patient’s history of falling.
Additional features occasionally seen on chest radiograph
(although not identified in this case) that might assist in
the diagnosis include the presence of a nasogastric or
nasointestinal tube within the left hemithorax.
Review of available imaging studies before and
throughout this patient’s hospital course give a better
Figure 3 – Portable chest radiograph obtained postoperatively after
laparoscopic repair of left diaphragmatic defect and gastrostomy tube
placement.
e95

Figure 4 – Coronal reconstruction of CT chest scan obtained before
admission. A lateral defect of the left hemidiaphragm is visualized with
mild herniation of the stomach into the left hemithorax.
sense of the chronology (and potentially pathogenesis)
of this patient’s condition. Figure 4 shows a coronal
image of a CT scan of the chest performed on the day
before admission. Here, the diaphragmatic defect is seen
laterally with mild herniation of intraabdominal
contents, including a relatively decompressed stomach.
A chest radiograph obtained postoperatively after his
tracheostomy and nasointestinal tube placement via
EGD (Fig 5) noted elevation of the left hemidiaphragm.
In hindsight, this appears to show an interval distension
of the gastric bubble within the left hemithorax,
potentially caused by gastric insufflation during the case.
Pathophysiology Discussion
In contrast to the more typical hiatal hernias, which
result in the displacement of the gastroesophageal
junction and additional portions of the stomach through
the natural aperture of the diaphragm, a defect of the
lateral portion of the diaphragm must be present for this
patient’s condition to exist. Such defects are either
congenital or acquired in the context of trauma.
Diaphragmatic injuries occur in approximately 0.1% of
thoracic blunt trauma and 3% to 5% of blunt abdominal
trauma, and have been associated with herniation of
abdominal contents, such as the stomach and small
bowel, into the thorax.2
Tension physiology, as suggested in this case, refers to a
process that both reduces pulmonary compliance and can
produce a form of obstructive shock by limiting venous
return. Classically, this is described in the context of
pneumothorax; however, several conditions can have a
e96 Chest Imaging and Pathology for Clinicians
Figure 5 – Portable chest radiograph obtained immediately post-
operatively after tracheostomy placement. There is loss of the normal
diaphragmatic contour on the left (solid arrow). The gastric bubble as
well as the lining of the stomach is visible within the left hemithorax
(empty arrow).
similar presentation.3 Other pleural diseases such as
empyema or malignant pleural effusions have been
described to exhibit tension physiology, with a common
element being the formation of mass effect within a
hemithorax resulting in the contralateral shift of
mediastinal structures as well as compression of lung
parenchyma.4,5 Hyperinflation secondary to emphysema
can also limit the diaphragm’s ability to descend normally
with inspiration, and decreased superior vena cava return
has been noted in patients with COPD, particularly
during expiration.6 Additionally, intraabdominal
hypertension (such as in reperfusion injuries, pancreatitis,
or massive ascites) can have a similar presentation by
limiting diaphragmatic excursion and limiting venous
return from the inferior vena cava.7
For a gastrothorax to develop tension physiology like
other intrathoracic causes, there must be some situation
that predisposes for additional gastric insufflation as well
as inefficient release of pressure (eg, belching or
vomiting).8 In the case presented, one might query
whether this could have taken place during the EGD
performed at the time of tracheostomy and
nasointestinal tube placement. Once the insufflated
stomach herniated into the thoracic cavity, the
diaphragmatic defect may have acted as a one-way valve
with impaired function of the normal gastroesophageal
junction. Enlargement of the intrathoracic stomach
could then create mass effect within the left hemithorax.
This reduction of venous return could manifest as a
form of obstructive shock with hypotension and
tachycardia.8
[ 162#2 CHEST AUGUST 2022 ]
Conclusions
Tension gastrothorax is characterized by the
presence of herniated intraabdominal contents such
as the stomach causing mediastinal shift and
hemodynamic compromise. Although uncommon, in
the right clinical context, one should consider the
possibility of tension gastrothorax when a patient
develops signs of obstructive shock. Chest imaging
can assist in the diagnosis and can differentiate
gastrothorax from pneumothorax or other pleural
pathology.9
Initial management includes early surgical evaluation,
gastric decompression with nasogastric or orogastric
tube, and subsequently endoscopic decompression, with
surgical gastropexy having a role in aiding in definitive
management.10
Acknowledgments
Financial/nonfinancial disclosures: None declared.
10. Gandhi S, Bhandarwar A, Sadhwani N, Patel C, Wagh A, Arora E.
Other contributions: CHEST worked with the authors to ensure
that the Journal policies on patient consent to report information
were met.
chestjournal.org
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