An 82-year-old woman presented to our hospital emergency department because of repeated vomiting that persisted for 2 days without induction. She had a history of cerebral infarction, hypertension, dementia, and surgery for a perforated sigmoid diverticulum. An upper gastrointestinal endoscopy had been performed at another hospital a month ago, but no abnormalities were noted. A physical examination revealed consciousness corresponding to the Glasgow Coma Scale score of 12 (E4V3M5), blood pressure of 98/71 mmHg, pulse of 119/min, temperature of 36.5 C, tachypnea (>=30 times/min), and 85% oxygen saturation (on room air), with diminished breath sounds on the left side. Chest X-ray revealed a large gastric bubble in the left chest cavity, with the mediastinum strongly displaced to the right side (Fig. 1A). Oxygen at 5 L/min improved the oxygen saturation (SpO2) to 92%, but tachypnea and tachycardia persisted. We speculated that a worsening esophageal hiatal hernia was probably responsible for the deterioration in respiration and circulation. Computed tomography (CT) performed for a definitive diagnosis showed that the entire stomach had escaped into the mediastinum and that it was craniocaudally inverted with axial torsion. In addition, the mediastinum had undergone a remarkable shift to the right owing to the presence of the dilated stomach; other structures, such as the left lung, heart, and inferior vena cava, were also highly displaced. There was no evidence of pneumonia (Fig. 2). Her condition deteriorated to agonal respiration with worsening tachycardia (120-150 times/min) when she returned to the emergency room after the CT scan, and assisted ventilation was immediately initiated. Subsequently, she developed pulseless electrical activity. Cardiopulmonary resuscitation was immediately initiated. CT findings suggested that the dilated stomach, along with the esophageal hiatal hernia, was strongly pressing on the heart, thereby disrupting circulation. Therefore, a gastric tube was used to decompress the stomach through which 1,400 mL of gastric fluid was aspirated. A spontaneous heartbeat resumed immediately, with stable circulation. Chest X-ray performed after the gastric tube insertion revealed normal mediastinal structures and the absence of the previously present giant gastric bubble in the mediastinum (Fig. 1B). Subsequently, the correction of dehydration by infusion stabilized both the blood pressure and tachycardia; however, because she developed aspiration pneumonia, her respiratory status did not improve and she died on the fourth hospital day (Fig. 3).
Chest and abdominal computed tomography scans (plain films) showing a significantly dilated stomach incarcerated within the mediastinum. A marked displacement of the heart and the left lung can be observed. Craniocaudal inversion of the incarcerated stomach, leading to an "upside-down stomach," can also be visualized. IVC, inferior vena cava.