An 18-year-old Burmawi man presented with abdominal pain and vomiting of blood of 2 days' duration. The pain started suddenly, mainly in the epigastrium, which increased when lying down, with no radiation. The patient gave a history of vomiting blood four times per day, 50–100 ml each time, but denied any history of drug taking and malena. His past history was significant due to blunt abdominal trauma during a road traffic accident. On examination, he was anxious with blood pressure of 90/70 mm Hg in supine posture, pulse rate 122/min and respiratory rate 24/min. Cardiovascular examination revealed tachycardia. The abdomen was soft with guarding and tenderness over the epigastrium, positive bowel sound and no organomegaly. Investigations revealed a haemoglobin level of 7 g/dl (normal 14–16 g/dl); serum chemistry, coagulation profile and platelet count was normal but leucocyte count was 14 000/(normal 4000–11 000/cm3). His chest x-ray revealed air-fluid level on the left side (). The patient was resuscitated with blood transfusions.
Chest x-ray showing hydropneumothorax.
Oesophagogatroscopy was performed, which revealed active bleeding from the gastric fundus and a doubtful mass. The procedure was abandoned and the patient was taken to the operation theatre.
With laparoscopy there was strangulated hiatus hernia (stomach and omentum), which could not be reduced laproscopically. Laparotomy was performed and the stomach and omentum were reduced from the thoracic cavity. Findings of gangrenous, but not perforated, stomach and adherent omentum were noted and resected from the lower end of the oesophagus to the antrum. Gastrectomy with oesophago-jejunostomy and jejunojejunostomy side-to-side anastomosis were done. The patient was transferred to the intensive care unit. The postoperative period was uneventful. CT scan without oral contrast was done on the fourth postoperative period, which revealed left pleural effusion and collapsed lung (). Barium follow-through was done 2 weeks later, which showed maintained anastomosis (), and the patient was discharged home on special dietary instructions.
CT scan showing residual pleural effusion and collapsed lung.
Barium follow-through showing delineation of small bowel and jejunumpostoperatively.