Acute gastric dilatation causing respiratory distress

A 64-year-old man was referred to the on-call surgical team from the High Dependency Unit with acute abdominal distension. He had undergone elective abdominal aortic aneurysm (AAA) repair two days previously. The patient had not vomited, was diaphoretic, and had difficulty speaking due to discomfort and respiratory distress. He was tachypnoeic with a respiratory rate of 24/min, tachycardic at 110 bpm, and hypotensive at 90/60 mmHg. Pulse oximetry demonstrated adequate saturations of 96% on FiO2. An ECG confirmed sinus rhythm without ischaemic changes. On respiratory examination there were globally reduced breath sounds consistent with hypoventilation. The abdomen was tense, markedly distended but only minimally tender, and a pronounced succussion splash was elicited by gently rolling the patient. Review of the fluid balance chart revealed liquid feeding by nasogastric tube and 1 L intravenous fluid administration 8-hourly, and oliguria with urine output <30 mL in 4 hours. The initial concern was that of abdominal compartment syndrome. Since the nasogastric tube was in situ, aspiration of gastric contents was attempted given the clinical findings, with removal of over 5 L of liquid feed. Abdominal girth decreased markedly, and ventilatory function correspondingly improved. The patient subsequently made a rapid recovery and was discharged one week later. Case 2