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Tension pneumothorax, bulla, and gastrothorax

Homepage: EMNote.org Tension pneumothorax, bulla, and gastrothorax. Tension pneumothorax, tension bulla, and tension gastrothorax are three distinct medical conditions that share similar manifestations and similar characteristics on chest X-rays. Clinical diagnosis in the acute setting can be challenging since they all present with respiratory distress, chest pain, and tachycardia. On Chest X-Ray, large radiolucent air-filled cavity is seen almost occupying the hemithorax, causing mediastinal shift and tracheal deviation. The air-filled cavities are free of lung markings and may represent an massive intrapleural gas, a giant pulmonary bulla, or a distended stomach. Tension pneumothorax occurs due to the progressive accumulation of intrapleural gas in the thoracic cavity caused by a valve effect during inspiration and expiration. Tension pneumothorax may be associated with rib fractures and subcutaneous emphysema in the setting of trauma. Tension bullae are air-filled sacs in the lung that become enlarged and under pressure, causing compression of surrounding lung tissue. A rapidly expanding bulla may resemble the same clinical presentation as tension pneumothorax. Tension gastrothorax is a rare life-threatening condition caused by mediastinal shift due to a distended stomach herniating into the thorax through a diaphragmatic defect. The stomach is distended with trapped air due to one way valve mechanism created by the collapsed pylorus and kinking of the gatro-oesophagal junction. Tension pneumothorax requires immediate chest decompression. Patient should not be sent to CT scan before chest tube insertion. CT scan of tension bullae may show intact diaphragms and massive bullae with thin-wall septae. The wall of the bullae may sometimes be misinterpreted as a pleural line and can be confused with pneumothorax on a chest X-ray. CT scan is the best way to evaluate the diagnosis of tension gastrothorax, with identification of communication between the stomach and thorax. Chest CT scans can show the stomach herniated through the diaphragmatic defect with significant distension with or without air-fluid level. Treatment of tension pneumothorax, tension bulla, and tension gastrothorax are different. Tension pneumothorax requires needle decompression or finger thoracostomy, followed by chest tube insertion. Tension bullae may be observed with O2 supplement, but surgical resection may be necessary in severe cases. Tension gastrothorax requires nasogastric tube decompression of the stomach and surgical repair of the diaphragm. Take Home Message. Tension pneumothorax, tension bulla, and tension gastrothorax are three distinct medical conditions that share similar manifestations and similar characteristics on chest X-rays. Clinical diagnosis in the acute setting can be challenging since they all present with respiratory distress, chest pain, and tachycardia. CT scan plays a major role in differential diagnosis. Tension pneumothorax requires needle decompression or finger thoracostomy, followed by chest tube insertion. Tension bullae may be observed with O2 supplement, but surgical resection may be necessary in severe cases. Tension gastrothorax requires nasogastric tube decompression of the stomach and surgical repair of the diaphragm.