An elderly female with a history of hiatal hernia and respiratory distress.

Abstract

An 81-year-old female with a past medical history of hiatal hernia presented to the emergency department with respiratory distress. The patient was afebrile, tachycardic, hypoxic, and tachypneic with cyanosis, retractions, and significant jugular venous distention. Point-of-care ultrasound revealed no pericardial effusion and bilateral lung sliding, though the inferior vena cava was not visualized. Chest x-ray revealed a massive hiatal hernia (Figure 1A). Nasogastric tube placement was attempted unsuccessfully by multiple clinicians. Subsequent computed tomography (Figures 2 and 3) demonstrated the mass effect of the stomach on the heart. Fluid resuscitation and broad-spectrum antibiotics were administered; however, the patient continued to decompensate. A nasogastric tube was successfully placed by the most experienced nurse in the department, with 2 L of gastric contents rapidly evacuated (Figure 1B) and immediate improvement in the patient's hemodynamic and respiratory status. The patient underwent surgical consultation but ultimately decided against surgery and was admitted for non-operative management. Here, we present a case of tension gastrothorax, an emergent, life-threatening condition leading to acute, severe respiratory distress and obstructive shock secondary to mass effect from the stomach herniating into the chest. The incidence is more common in children with congenital diagphragmatic hernia and patients with acute trauma.1, 2 Immediate decompression of the gastric lumen can lead to physiologic improvement in symptoms as a temporizing measure.3 Surgical consultation for reduction of gastric contents into the abdomen should be obtained for definitive care.3