(860) Tamponade as a Delayed Complication of Ruptured Gastrothorax

Introduction: Tension gastrothorax, where the stomach herniates into the thorax through a diaphragmatic defect, remains inadequately documented in the literature. In this report, we present a 4-year-old male with an undiagnosed left-sided congenital diaphragmatic hernia (CDH) that progressed to tension gastrothorax, gastric rupture, and concurrent pleural and pericardial effusions.

Description: A 4-year-old boy presented to an outside emergency department with sudden-onset respiratory distress, which rapidly escalated to shock and respiratory failure. Urgent resuscitation included needle decompression due to concern for hydropneumothorax on imaging, which yielded dark fluid without any air excursion. Following transfer, chest X-ray revealed left hydropneumothorax, right pleural effusion, and pneumoperitoneum. An exploratory laparotomy unveiled intrathoracic herniation of the spleen and stomach through a diaphragmatic defect. The stomach fundus had perforated releasing gastric contents into the chest and abdomen. Surgical repair and bilateral chest tube placement were performed. Culture-guided antibiotic therapy led to gradual clinical improvement. However, on the 16th day of hospitalization, the patient developed tachycardia initially attributed to pain management. Subsequently, shock ensued, and the patient suffered a cardiac arrest secondary to pericardial effusion with tamponade physiology. Resuscitation involved pericardial drain placement, resulting in improved hemodynamics. Despite complications related to infection and prolonged antibiotic therapy, the patient was eventually discharged home in stable condition.

Discussion: While several case reports have discussed gastrothorax in the context of delayed CDH presentations or after trauma, most of these cases were managed before they progressed to rupture. With little literature documenting complications of a ruptured gastrothorax, maintaining a high index of suspicion is crucial for recognizing pericardial effusion as a potential complication and preventing emergent situations. Notably, pericardial effusion developed later in this patient’s clinical course while receiving the appropriate antimicrobial therapy and source control with bilateral chest tubes, suggesting an inflammatory process rather than an infectious etiology.