Swallowing Air

Have you ever considered swallowed air to be hazardous to a diver? Or thought that a good belch before a dive may be a smart safety move?

Undercurrent subscriber Daniel Spitzer, M.D., and fellow diver and surgeon Lee Fleisher, M.D., encountered a unique and serious diving malady in a patient at Good Samaritan Hospital in Suffern, N.Y. They were kind enough to share it with us as a warning to fellow divers:

L.L., a previously healthy, 34-yearold man, recently underwent emergency laparotomy -- an incision through the abdominal wall -- for repair of a gastric perforation.

L.L. had been certified for approximately fourteen years and had undertaken approximately seventy-five dives, all without incident. He arrived at the Turquoise Reef Resort in Providenciales, Turks and Caicos, in early February. Bad weather prevented diving for three days, during which he had no diarrhea, constipation, nausea, stomach pain, or other gastrointestinal symptoms.

Although L.L. normally eats a moderate breakfast, the morning before his first dive he had only a cup of coffee. He had rented a wetsuit, which made him feel somewhat claustrophobic. The dive was to 45 feet; during the descent he did not feel well, and tried to relax and control his breathing, since he felt he was sucking a great deal of air. He spent 5-10 minutes at depth, and then developed shortness of breath. He took a minute or two to ascend, and, once on the surface, he had increased shortness of breath. He swam to the boat, where he had to be dragged on board.

He then noted that his abdomen was extremely distended and rockhard. An x-ray at the local health care facility revealed free air in his abdomen. On Provo, he underwent an emergency mini-laparotomy via a 2- inch incision that released the air pressure and eased his breathing. He was then flown by Medivac to Jackson Memorial Hospital in Miami, where he was observed for twenty-four hours and then released. He took a commercial flight back to New York.

Two days later he collapsed, and was taken to Good Samaritan Hospital. Free air was again discovered in his abdomen, and he had a very low blood count from a gastrointestinal hemorrhage. A laparotomy revealed a 2-cm. perforation in his stomach with active bleeding, but no other abnormality. The perforation was repaired, and he has recovered.

The presumed diagnosis is gastrointestinal barotrauma, probably due to swallowed air -- something that we all do, although we usually routinely belch it up. In L.L.'s case, however, the gastric air probably ruptured the stomach and entered the abdominal cavity as he began his ascent. The abdominal or intraperitoneal air then further expanded as L.L. continued to ascend, causing abdominal distention, pressure on the diaphragm, and labored breathing. The minilaparotomy released enough pressure to relieve most of his symptoms.

The textbook Diving And Subaquatic Medicine, by Edmonds, et al., (3rd ed., Butterworth, 1992), notes that one case of a burst stomach following a rapid and uncontrolled diving ascent has been recorded. The rupture required surgical exploration and repair. Additional cases have been reported elsewhere.

According to Edmonds, et al., imbibing carbonated beverages, even those seemingly flat when drunk, may be a risk factor. And Dr. Spitzer wonders whether a second stage with too low a cracking pressure -- one that almost pushes air into your mouth -- might also be a risk factor.