A 53‐year‐old man was transferred to our hospital for renal failure, uremic encephalopathy, and septic shock. The patient had recently become reclusive and family reported 3‐4 weeks of nausea, vomiting, and diarrhea without seeking medical attention. He was lethargic with a blood pressure of 85/49 mm Hg. pulse 82/minute. and respirations 27/minute. There was marked distension of the jugular veins. There were decreased bowel sounds, and the abdomen was distended and tender to palpation. The WBC count was 28,300/pL, urea nitrogen 178 mg/dL, and creatinine 8.7 mg/dL. The arterial blood gas was pH 7.17, pCO2 27 mm Hg, pO2 55 mm Hg, bicarbonate 17 mmol/L, and oxygen saturation 81% on room air Chest and abdominal radiographs revealed elevation of the right hemidiaphragm and distension of intra‐abdominal bowel. Computed tomography showed bilateral pleural effusions, right basilar atelectasis, intraperitoneal fluid, and scattered air‐fluid levels throughout the ascending and Iransverse colon. Aggressive fluid resuscitation and vasopressors were required. Bedside transthoracic echocardiography demonstrated dilated bowel loops within the chest cavity compressing the right atrium. The left ventricular end diastolic volume was low. The patient was referred for surgery. In the operating room, pneumoperitoneum and diaphragmatic eventration were found; Ihe ascending and Transverse colon along with the liver were in the thorax. Intraoperative transesophageal echocardiography showed normalization of right atrial and right ventricular filling on removal of the abdominal organs from the chest with associated hemodynamic improvement. Additional findings included a perforated transverse colon, perforated cecum, and 6 L of fecal liquid in the abdomen. Right hemicolectomy and diaphragm plication were performed. Histopathology reports showed colonic gangrene consistent with herniation and compression. He improved significantly over the next several days and was eventually discharged.
Right atrial compression may be caused by aortic aneurysms, traumatic diaphragmatic herniation, sequela of aortic valve replacement, and mediastinal tumors. These patients classically present as mimics of pericardial tamponade. Rarely has diaphragmatic eventratior been reported to cause compression of the right atrium leading to hemodynamic compromise.
Clinical judgment can be The physician's best tool for making difficult diagnoses when a patients presentation does not correspond to the results of diagnostic testing. In this case, the patient was transferred with a suspicion of septic shock but physiology mimicking cardiac tamponade was discovered and allowed a unique cause of right atrial compression from diaphragmatic eventration to be identified and treated.
J. Foreman, none; D. DeLeon, none; R. Murchison, none; C. Butcher, none.