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A 27-year-old man was admitted to the emergency department because of respiratory failure. Three years earlier, he had undergone surgery to repair a traumatic rupture of the left side of the diaphragm. On admission, the patient had severe respiratory distress, hypotension (blood pressure, 60/40 mm Hg), and sinus tachycardia (heart rate, 140 beats per minute). There was a rightward deviation of the trachea and distention of the neck veins. On examination, the left hemithorax was hyperresonant and without breath sounds. Heart sounds and normal breath sounds were heard to the right of the sternum. In view of the patient's history, a chest radiograph was obtained (Panel A) before thoracentesis was performed. The radiograph showed massive intrathoracic gastric dilatation with a rightward shift of the mediastinum. A nasogastric tube was immediately placed, and large amounts of gas and fluid were drained. Dramatic clinical and radiographic improvement was noted by the following day (Panel B). A few days later, the patient underwent a second operation to repair the recurrent left-sided diaphragmatic rupture and had no further complications.
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