Tension Viscerothorax with Concomitant Pneumothorax and Associated Intrathoracic Gastric Perforation after Thoracoabdominal Stab Wound in a Resource-Limited Setting: A Case Report

Abstract

INTRODUCTION: Traumatic diaphragmatic injury after penetrating thoracoabdominal trauma is rare and can be missed when CT is not available. Tension viscerothorax can mimic tension pneumothorax and may persist despite pleural decompression. CASE PRESENTATION: A 28-year-old man suffered a knife stab to his left posterior thoracoabdomen. A 28-French left chest tube inserted at a local health center for a suspected tension pneumothorax (without imaging) did not improve the patient's condition, and later drained the gastrointestinal (GI) content. Upon arrival, chest radiography revealed a left pneumothorax with a severe mediastinal shift to the right, as well as a gastric air bubble and bowel loops in the left hemithorax. Focused assessment with sonography for trauma (FAST) showed a large left pleural fluid collection and splenorenal fluid accumulation. Nasogastric decompression aspirated air and 300 mL of GI fluid with partial improvement. Emergency laparotomy revealed a 10-cm left diaphragmatic laceration (American Association for the Surgery of Trauma grade III) with immediate multivisceral herniation, a jejunal serosal tear, and an associated through-and-through fundal gastric perforation, contaminating the pleural and peritoneal cavities. Primary repair of the gastric, jejunal, and diaphragmatic injuries, combined with lavage and revision of the chest tube, achieved source control. He was discharged on POD 8 and remained symptom-free without recurrence at 12-month follow-up. CONCLUSIONS: In resource-limited settings, persistent obstructive physiology despite tube thoracostomy, especially when accompanied by bowel sounds in the hemithorax or enteric drainage through the chest tube, should prompt suspicion for tension viscerothorax. Classical clinical findings, together with chest radiography, FAST, and early nasogastric decompression, can justify timely definitive surgery even when CT is unavailable.