Asian Cardiovasc Thorac Ann 2001;9:342-343
© 2001 Asia Publishing EXchange Pte Ltd
Epigastric Pain After Tube Thoracostomy: a Case of Vagal Irritation
Seyda Ors Kaya, MD,
Gokhan Yuncu, MD,
Alpaslan Cakan, MD
Department of Thoracic Surgery Chest Diseases and Thoracic Surgery Training Hospital  zmir, Turkey
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For reprint information contact: Alpaslan Cakan, MD Tel: 90 232 433 3333 Fax: 90 232 339 0002 email: alpcakan{at}gohip.com Mithatpa a Caddesi No. 739, Daire: 1, Göztepe, zmir 35290, Turkey.
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ABSTRACT
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A 58-year-old man with spontaneous pneumothorax experienced severe burning pain in the epigastric region after insertion of a chest tube. Chest radiography showed malposition of the tube, abutting the mediastinum. On suspecting that the vagus nerve had been stimulated by the tip of the tube, the tube was withdrawn 3 cm, and the pain disappeared completely.
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INTRODUCTION
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Tube thoracostomy is a common procedure in the treatment of spontaneous pneumothorax.1 There are rare complications of tube thoracostomy such as Horner's syndrome, phrenic nerve paralysis, and fatal parasympathetic stimulation, besides the well-known complications of empyema, hemothorax, and traumatic injury of the diaphragm and abdominal viscera.2–5 A previously unreported complication associated with tube thoracostomy is described.
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CASE REPORT
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A 58-year-old man was admitted with a one-week history of chest pain and dyspnea. Physical examination revealed decreased breath sounds in the right hemithorax. Chest radiography showed a partial pneumothorax on the right side. A 28F chest tube was inserted via the 5th intercostal space on the anterior axillary line, with local anesthesia. After insertion, a moderate bradycardia of 55 beats•min-1 developed and disappeared within 1 hour. The patient experienced severe burning epigastric pain radiating to the retrosternal area. Examination of the cardiovascular system was normal. Medical treatment including H2 receptor antagonists and antacids was of little benefit. A chest radiograph showed malposition of the chest tube, abutting the mediastinum (Figure 1
). Two days later, irritation of the vagus nerve was suspected, and the chest tube was pulled back approximately 3 cm. The patient's symptoms totally disappeared. On the 3rd day of tube thoracostomy, the right lung expanded completely, the chest tube was pulled out, and the patient was discharged from hospital.
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Figure 1. Chest radiograph showing malposition of the chest tube which abutted the mediastinum. The tip of the chest tube is indicated by arrows.
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DISCUSSION
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Some branches of the right vagus nerve go to the cardiac plexus which runs behind the right mainstem bronchus and gives major contributions to the anterior and posterior pulmonary plexuses. It passes along the right surface of the esophagus to form an esophageal plexus which makes the posterior vagal trunk before passing through the esophageal hiatus.6 In this patient, the chest radiograph showed that the tip of the tube was located against the pleura of the posterior mediastinum, at the level of the 8th and 9th vertebrae. It was suspected that stimulation of the vagus nerve due to malposition of the chest tube at this location might be the cause of the patient's symptoms. Parasympathetic stimulation causes a marked decrease in heart rate, of up to 20 to 30 beats•min-1 with maximum vagal stimulation. If the vagal stimulation is strong enough, the rhythmical self-excitation of the sinoatrial node can even stop.7 The bradycardia in this patient might have been compensated by other reflex mechanisms.
The parasympathetic fibers of the vagus nerve provide innervation to the esophagus, stomach, pancreas and intestines. Vagal stimulation excites stomach secretion directly by stimulation of the gastric glands and indirectly through the gastrin mechanism.7 Irritation of the vagus nerve should be considered a rare complication of malpositioned chest tubes. To our knowledge, epigastric pain has not been previously reported as a complication of tube thoracostomy.
Presented at the Second International Congress of Thorax Surgery, Bologna, Italy, June 24–6, 1998.
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REFERENCES
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Fry WA, Paape K. Pneumothorax. In: Shields TW, editor. General thoracic surgery. Philadelphia: Williams & Wilkins, 1994:662–73.
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Pearce SH, Rees CJ, Smith RH. Horner's syndrome: an unusual iatrogenic complication of pneumothorax. Br J Clin Pract
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Salon JE. Reversible diaphragmatic eventration following chest tube thoracostomy. Ann Emerg Med
1995;25: 556–8.[Medline]
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Ward EW, Hughes TE. Sudden death following chest tube insertion: an unusual case of vagus nerve irritation. J Trauma
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Gregoire J, Deslauriers J. Closed drainage and suction systems. In: Pearson FG, Deslauriers J, Ginsberg RJ, Hiebert CA, McKneally MF, Urschel HC, editors. Thoracic surgery. New York: Churchill-Livingstone, 1995: 1121–35.
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Kubik S. Surgical anatomy of the thorax. Philadelphia: Saunders, 1970:173–83.
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Guyton AC. Textbook of medical physiology. Philadelphia: Saunders, 1986:160 & 776.
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ABSTRACT
INTRODUCTION
