Critical Care and Shock

Gastromegaly as the cause of unexplained chest pain

A 61-year-old gentleman with past medical history of hypertension, hyperlipidemia, gastroesophageal reflux status post hiatal hernia repair in 1973, and recurrent diverticulitis was admitted to the intensive care unit (ICU) after undergoing elective laparoscopic recto-sigmoid hemicolectomy and colostomy formation. His immediate postoperative course was complicated by syncope while getting out of bed to ambulate. The patient regained consciousness within minutes and noted severe substernal chest pressure and dyspnea at rest. Physical examination revealed a blood pressure of 70/40 torr, heart rate 130/min and respiratory rate 28/min. Chest examination was unremarkable. Mild abdominal distension was noted without discomfort to palpation, and diffuse tympani on percussion. An emergent electrocardiogram was unremarkable. The patient received intravenous fluids and vasopressors. Laboratory testing revealed acute blood loss anemia with drop in baseline hemoglobin of four grams per deciliter. Following stabilization while awaiting blood transfusion, a chest X-ray was performed demonstrat­ing severe gastromegaly, which was then confirmed by abdominal X-ray (Figures 1 and 2). Subsequent abdominal and pelvic computed tomography (CT) with contrast to assess for obstruction, confirmed the pres­ence of gastromegaly without obstruction, and left lower quadrant hematoma without active bleeding (Figure 3). A nasogastric tube on continuous suction was inserted with subsequent resolution of the patient’s symptoms as well as the objective findings of hypotension, tachy­cardia, and tachypnea. A repeat radiograph revealed decompression of the patient’s stomach (Figure 4). Pressor support was weaned, and after completion of the patient’s blood transfusion, stopped. The patient had no further complications post-operatively and discharged home on post-operative day 2.

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