Gastric dilatation and intestinal obstruction mimicking acute coronary syndrome with dynamic electrocardiographic
H M M T B Herath1, Anne Thushara Matthias2, B S D P Keragala2
1National Hospital, Colombo, Sri Lanka. tharukaherath11@gmail.com.
Insights
Acute intestinal obstruction can mimic ST elevation myocardial infarction on ECG. Early recognition of non-cardiac causes like gastric distension prevents unnecessary cardiac interventions and patient anxiety.
Area of Science:
- Cardiology
- Gastroenterology
Background:
- ST elevation myocardial infarction (STEMI) is a critical diagnosis often reliant on electrocardiogram (ECG) findings.
- Non-cardiac conditions can present with ECG changes mimicking acute coronary syndrome (ACS).
- Few reported cases link gastric distension and intestinal dilatation to acute ST segment elevation on ECG.
Observation:
- A 56-year-old male presented with symptoms of partial intestinal obstruction, including nausea, vomiting, and abdominal distension, but no chest pain.
- ECG revealed ST elevations in anterior leads (V1-V3) and inferior leads (II, III, aVF), suggestive of anterior STEMI.
- Normal cardiac biomarkers and echocardiogram ruled out acute myocardial injury, while abdominal X-ray confirmed gastric and colonic dilatation.
Findings:
- Dynamic ECG changes, including ST elevations, resolved with the alleviation of bowel obstruction.
- The proposed mechanism for ECG changes involves positional alteration of the heart due to severe gastric distension and intestinal dilatation.
- Normal cardiac biomarkers and echocardiogram were crucial in differentiating from actual myocardial infarction.
Implications:
- This case underscores the importance of considering non-cardiac etiologies for ECG abnormalities that mimic STEMI.
- Thorough patient history and targeted investigations (cardiac biomarkers, echocardiogram, abdominal imaging) are vital in complex diagnostic scenarios.
- Prompt identification of conditions like acute gastric distension can prevent unnecessary invasive procedures, costly treatments, and patient distress.
Background:
ST elevation myocardial infarction is a medical emergency and the electrocardiogram is a part of the mainstay in the initial diagnosis. A variety of non-cardiac conditions have been known to mimic the electrocardiographic changes seen in acute coronary syndrome. We present a patient presenting with acute partial intestinal obstruction causing gastric distension and intestinal dilatation who also had dynamic electrocardiographic changes, mimicking anterior ST elevation myocardial infarction. Only very few cases of gastric distention and intestinal dilatation leading to acute ST segment elevation in electrocardiogram are reported so far in literature.
Case Presentation:
A fifty-six-year-old Sri Lankan male, without any modifiable risk factors for ischemic heart disease presented with acute onset nausea, vomiting, sweating, abdominal discomfort and fullness without any chest pain. On examination, he had a pulse rate of 50 beats per minute and his blood pressure was 110/50 mmHg. His abdomen was distended and the liver dullness was not detectable. Subsequent ECG showed > 2 mm ST elevations with T inversions in chest leads V1 to V3, J point elevation in leads L 11, L 111, aVF and T inversion in leads L 1 and aVL. Cardiac biomarkers were normal and 2D echo showed normal left ventricular function without any regional wall motion abnormalities. Abdominal X-ray showed a distended stomach, dilated ascending and descending colon with absent rectal air. Electrocardiographic changes reverted back to normal with the resolution of bowel obstruction.
Conclusion:
The mechanism of ECG changes in such a case like this is yet to be elucidated, but can be postulated to happen due to change in the position of the heart in the thoracic cavity causing change in the cardiac axis. This case emphasizes the importance of a proper history and highlights the value of auxiliary investigations such as cardiac biomarkers and echocardiogram in the diagnosis of acute coronary syndrome in a confusing situation such as this. This also illustrates the importance of early recognition of other noncardiac causes like acute gastric distention as being responsible for dynamic ECG changes. This will obviate a myriad of unnecessary investigations, interventions, costly management strategies and patient anxiety.
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