Tension pneumothorax, bulla, and gastrothorax

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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

• 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

• 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

• 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.

Diagnosis:

• 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:

• 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.