Gastric dilatation as a cause of acute respiratory distress

Case description

An 86-year-old man developed acute dyspnea in a community hospital. He suffered from numerous morbidities: chronic renal failure, requiring peritoneal dialysis; inoperable ischemic heart disease; congestive heart failure; gastroesophageal reflux; hyperlipidemia; and a right pleural effusion, requiring drainage. At the request of the nursing staff, the hospitalist attended the patient late in the evening. The patient had developed acute dyspnea. Before the physician’s arrival, the nursing staff had administered salbutamol and ipratropium, with no effect.

During the preceding day, he had complained of epigastric discomfort and nausea. He had 1 episode of vomiting that day. Measurement of his vital signs revealed the following: pulse of 136 beats/min, respiratory rate (RR) of 26 breaths/min, and blood pressure (BP) of 129/70 mm Hg. On admission his vital signs had been the following: pulse of 77 beats/min, RR of 12 breaths/min, and BP of 111/64 mm Hg. His oxygen saturation was 92%; on admission it had been 96%.

The right lung had decreased air entry with wheeze from the previously documented pleural effusion. The left lung had decreased air entry in the base and was diffusely wheezy. An electrocardiogram revealed no acute ischemic changes. A chest x-ray scan revealed the previously noted pleural effusion on the right and a large gastric bubble pushing on the left diaphragm (Figure 1). There was no intestinal dilatation or evidence of any other air fluid levels. A nasogastric tube was placed and subsequently drained 1 L of fluid. The patient had prompt relief of his symptoms. The wheeze disappeared from his lungs and the air entry returned to normal on the left. His pulse dropped to 107 beats/min; his RR was 20 breaths/min and his BP was 122/57 mm Hg. The following morning an x-ray scan revealed a diminished gastric bubble and no evidence of free air or bowel obstruction. The nasogastric tube was removed 2 days after insertion, with no sequelae.

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Figure 1

Chest x-ray scan revealing a pleural effusion on the right and a large gastric bubble pushing on the left diaphragm

Conclusion

Early recognition of gastric dilatation with prompt decompression will usually result in immediate improvement in the patient’s condition. It is important to keep gastric dilatation on the differential diagnosis for dyspnea, especially in the face of other comorbidities, which might distract the investigation but prove not to be the cause of the patient’s distress.