Tension gastrothorax due to a Bochdalek hernia with gastric volvulus in an adult

CASE DESCRIPTION

A 25-year-old female presented to the emergency room with dyspnea, abdominal pain, and constipation for five days. On examination, the patient was noted to have a pulse rate of 104 beats and was tachypneic. Oxygen saturation was 93% on room air, while blood pressure remained within normal limits. Examination revealed absent breath sounds over the left side and a soft, non-tender abdomen. A chest radiograph showed a significant right mediastinal shift with an air-fluid level in the left hemithorax, causing left lung collapse [Figure 1a]. Cross-sectional imaging identified a 6 × 8 cm defect in the left hemidiaphragm, causing herniation of the stomach with significant organoaxial rotation and complete spleen [Figure 1b and 1c]. The patient underwent emergency laparoscopic surgery, converted to laparotomy, involving partial gastric sleeve resection (gangrenous fundus), diaphragmatic hernia tissue repair, and gastropexy. A chest x-ray on postoperative day 1 demonstrated left lung re-expansion, a midline trachea, and an intercostal drain in situ [Figure 1d]. The patient had an uneventful postoperative period and was subsequently discharged after 5 days. Unfortunately, the laparoscopic operative video and image recordings were corrupted and could not be submitted.

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Figure 1:

(a) Preoperative chest x-ray with significant right mediastinal shift (arrow) with an air-fluid level in the left thoracic cavity, causing left lung collapse, (b) Coronal CT showing a herniated, volvulized stomach in the left thoracic cavity (arrow), causing right mediastinal shift, (c) Sagittal CT showing a 6 × 8 cm defect in the left hemidiaphragm, causing herniation of the stomach with organoaxial rotation and spleen (arrow), (d) Postoperative chest x-ray showing left lung re-expansion, midline trachea, and left intercostal drain in situ. CT: Computed tomography.

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The Bochdalek hernias are posterolateral congenital diaphragmatic defects, observed in 0.03% of live births, with a higher incidence in males. They constitute 80-90 % of the congenital diaphragmatic hernia cases.¹ The prevalence of Bochdalek hernias in adults remains unclear; however, the overall incidence of diaphragmatic hernias in adults is reported to range from 0.17% to 6%. Very few adult Bochdalek hernias have been documented in the literature.^2,3 Tension gastrothorax, characterized by massive distension of the herniated stomach into the thoracic cavity, was first described in the literature in 1984 by Ordog et al. in an adult patient as a complication of post-traumatic diaphragmatic rupture.⁴

Patients presenting with sudden-onset breathlessness and gastrointestinal obstruction symptoms with air-fluid levels on chest radiographs should prompt suspicion of gastrothorax or massive diaphragmatic hernia over hydropneumothorax. Placing an intercostal drain in patients with gastrothorax, mistaken for hydropneumothorax, can significantly increase morbidity. In case of mediastinal shift or hemodynamic instability secondary to intrathoracic gastric distension, initial management should focus on reducing gastric tension through nasogastric tube, endoscopic decompression, or transthoracic needle decompression.⁵ When the nasogastric decompression fails, the role of emergency transthoracic needle decompression of the stomach as a temporizing intervention warrants evaluation in adult patients.

Recent guidelines recommend mesh reinforcement for large diaphragmatic defects when tension-free primary closure is not achievable, as this may reduce recurrence.^6,7 In emergency settings with contamination, strangulation, or gangrenous viscera, prosthetic mesh use is discouraged due to infection risk, and primary repair is preferred whenever feasible. Biological meshes have been proposed as alternatives in selected contaminated fields, owing to their improved resistance to infection; however, evidence supporting their routine use remains limited, and decisions should be individualized based on intraoperative findings.