Acute Pancreatitis Masquerading as Inferior Wall Myocardial Infarction: A Review

Acute pancreatitis presented with diffuse ST-segment elevation: A case report and literature review

INTRODUCTION

Although electrocardiographic changes have been previously reported in patients with acute pancreatitis, diffuse ST-segment elevation without occluded coronary arteries is rarely documented.

PATIENT CONCERNS

A 45-year-old man presented to our emergency department due to persistent epigastric pain for 2 hours. However, ECG in the emergency department revealed regular sinus rhythm at 67 beats per minute, peaked T waves in lead V3-5, and upsloping ST-segment elevation in leads II, III, aVF, and V2-6.

DIAGNOSIS

He was diagnosed with acute pancreatitis and presented with diffuse ST-segment elevation.

INTERVENTIONS

Laboratory workup and computed tomography supported the diagnosis of acute gallstone pancreatitis and endoscopic retrograde cholangiopancreatography was performed. Coronary angiography showed patent coronary arteries finally.

OUTCOMES

Endoscopic retrograde cholangiopancreatography and endoscopic papillo-sphincterotomy were performed, and the stone in the common bile duct was removed smoothly without immediate complication. Due to his relatively stable condition, he was discharged on day 7 of admission.

CONCLUSION

We presented an uncommon case of acute pancreatitis demonstrating similar features of AMI. This reminds cardiologists and emergency physicians to make the judgment with more caution to avoid jumping to conclusions and providing inappropriate treatment.

Necrotizing acute pancreatitis with electrocardiogram changes masquerading acute coronary syndrome

Acute pancreatitis (AP) refers to the acute inflammation of the pancreas; however, if there is concurrent necrosis, it is called necrotizing acute pancreatitis (NAP). The diagnosis is sometimes difficult because it might mimic acute coronary syndrome (ACS). We report a case of a 28-year-old male, who presented to the emergency department (ED) with severe epigastric pain, shortness of breath and diaphoresis for 4-5 h. The initial electrocardiogram (ECG) showed marked sinus bradycardia with an incomplete left bundle branch block. Considering the clinical presentation and ECG changes, he was managed as ACS and was rushed to catheterization laboratory for a coronary angiogram, which was reported normal. Subsequently, his serum pancreatic enzymes were elevated, and computed tomography of the abdomen showed NAP. In ED settings, it is difficult to differentiate between the two, particularly when AP presents with ECG manifestations masquerading as ACS.

Acute Pancreatitis Simulating Myocardial Infarction: A Challenging Case

Acute pancreatitis is an inflammatory condition with varying local and systemic complications and variable severity. Although rare, cardiovascular complications induced by acute pancreatitis are rarely described in the literature. Epigastric pain with acute pancreatitis often simulates electrocardiographic changes in the absence of coronary artery abnormalities, resulting in a diagnostic dilemma for optimal treatment and management. We underline a case of acute pancreatitis complicated by acute coronary syndrome in a patient who presented with chest heaviness, dyspnea, nausea, and worsening epigastric pain associated with vomiting. Clinical and laboratory evaluations and using imaging modalities were suggestive of acute pancreatitis mimicking myocardial infarction (MI) in the absence of coronary artery abnormalities.

Elevated troponin level and nonspecific ST‐segment and T‐wave changes in a suspected acute pancreatitis patient, post‐SARS‐Cov‐2 infection: A case report

The case report describes a post‐COVID‐19 patient with severe right upper quadrant (RUQ) pain, moderate epigastric pain, high troponin levels, and nonspecific ST‐segment and T‐wave changes on electrocardiogram (ECG).

Osteomyelitis of the Cervical Spine Presenting as Acute ST-Segment Elevation

Acute ST-segment elevation (STE) on electrocardiogram (EKG) is very frequently associated with myocardial infarction, which requires prompt diagnosis and treatment. However, there are multiple other causes of acute STE, both cardiac and noncardiac. Here we describe a unique case of acute inferior and lateral STE caused by osteomyelitis and abscess of the lower cervical vertebrae.

Case Report: Abnormal ECG in a Patient With Acute Pancreatitis

Background: Both acute pancreatitis and acute myocardial infarction (AMI) are rapidly progressive and frequently fatal diseases that can be interrelated and lead to a vicious cycle for further problems. The concomitant occurrence of AMI and acute pancreatitis is rare but critical, and efficient diagnosis and treatment of such patients are challenging.

Case Summary: We reported an uncommon case of abnormal ECG findings in a 63-year-old woman with acute pancreatitis. The patient exhibited increased biomarkers of myocardial injury, such as creatine kinase-MB (CK-MB) and troponin T, as well as ST segment elevation in inferior leads II, III, and aVF. Both of these have been previously observed in patients with acute abdomen in the absence of ST-segment elevation myocardial infarction (STEMI), including pancreatitis. In addition, lacking complaints of chest pain or tightness was also supportive of this idea. Echocardiography indicated abnormalities in the functioning of the left inferior posterior wall segments and decreased overall systolic function of the left ventricle with a 51% ejection fraction. Eventually, AMI was diagnosed after coronary computed tomography angiography (CCTA) showing critical stenosis of the right coronary artery and left anterior descending artery segments. The patient was urgently transferred to intensive care unit and was treated with anticoagulation, antiplatelet aggregation, lipid-lowering and other palliative drugs.

Conclusion: Concomitant acute pancreatitis and AMI are often considered to be critical conditions with a poor prognosis. Therefore, it is important to rapidly identify this condition and consider transferring patients for multidisciplinary supportive care.

Assessment of pain associated with chronic pancreatitis: An international consensus guideline

Pain is the most common symptom in chronic pancreatitis (CP) with a major impact on quality of life. Few validated questionnaires to assess pain in CP exist, and the lack of consensus negatively impacts clinical management, research and meta-analysis. This guideline aims to review generic pain questionnaires for their usability in CP, to outline how pain assessment can be modified by confounding factors and pain types, to assess the value of additional measures such as quality of life, mental health and quantitative sensory testing, and finally to review pain assessment questionnaires used specifically in CP. A systematic review was done to answer 27 questions that followed the PICO (Population; Intervention; Comparator; Outcome) template. Quality of evidence of the statements was judged by Grades of Recommendation, Assessment, Development and Evaluation (GRADE) criteria. The manuscript was sent for review to 36 experts from various disciplines and continents in a multi-stage Delphi process, and finally reviewed by patient representatives. Main findings were that generic pain instruments are valid in most settings, but aspects of pain are specific for CP (including in children), and instruments have to account for the wide phenotypic variability and development of sensitization of the central nervous system. Side effects to treatment and placebo effects shall also be considered. Some multidimensional questionnaires are validated for CP and are recommended together with assessment of quality of life and psychiatric co-morbidities. This guideline will result in more homogeneous and comprehensive pain assessment to potentially improve management of painful CP.

The way to a man's heart is through his stomach: a case of myocardial infarction mimic and pseudo-tamponade in a polytrauma patient

Background

There exists a therapeutic conflict between haemorrhage control and prevention of thromboembolic events following polytrauma and complications are not uncommon. Such opposing therapies can result in unexpected pathophysiology and there is a real risk of misdiagnosis resulting in harm. This case presents a previously unreported complication of prevention and management of thromboembolism- STEMI (ST elevation myocardial infarction) and tamponade mimic secondary to retroperitoneal haematoma.

Case presentation

We present a 50-year-old male polytrauma patient who following treatment for presumed pulmonary embolus demonstrated classical clinical findings of myocardial infarction and pericardial tamponade secondary to a retroperitoneal haematoma. This is an event not previously reported in the literature. The risk of adverse outcome by management along the standard lines of STEMI (ST elevation myocardial infarction) was averted through awareness for alternative aetiology via a multi-team approach which resulted in percutaneous drainage of the haematoma and complete resolution of symptoms.

Conclusions

This manuscript highlights the therapeutic conflict between haemorrhage control and prevention of thromboembolic events in critically injured, the importance of high index of suspicion in this patient cohort and the benefits of multidisciplinary decision making in the complex patient through a not previously published pathophysiologic phenomenon.

Rare Complication of Necrotizing Pancreatitis: Extension of Retroperitoneal Abscess into Femoral Region

Distant abscesses are uncommon during the episode of acute pancreatitis (AP). However, these are possible sequalae of necrotizing pancreatitis and should be treated appropriately to prevent serious septic complications. We demonstrate a case of a 56-year-old male patient who presented with severe necrotizing pancreatitis and distant retroperitoneal abscess that reached femoral region and was detected on diagnostic imaging scans. Combination of surgical and supportive therapy was employed, and the patient recovered well with no permanent consequences. Our article highlights the importance of quick and accurate diagnosis and timely intervention in this rare type of pancreatitis complication.

Influence of COVID-19 on lifestyle behaviors in the Middle East and North Africa Region: a survey of 5896 individuals

BACKGROUND

Coronavirus disease (COVID-19) pandemic has affected health and lifestyle behaviors of people globally. This project aims to identify the impact of COVID-19 on lifestyle behavior of individuals in the Middle East and North Africa (MENA) region during confinement.

METHODS

We conducted an online survey in 17 countries (Egypt, Jordan, United Arab Emirates, Kuwait, Bahrain, Saudi Arabia, Oman, Qatar, Yemen, Syria, Palestine, Algeria, Morocco, Libya, Tunisia, Iraq, and Sudan) from the MENA region on August and September 2020. The questionnaire included self-reported information on lifestyle behaviors, including physical activity, eating habits, smoking, watching television, social media use and sleep before and during the pandemic. Logistic regression was performed to analyze the impact of COVID-19 on lifestyle behaviors.

RESULTS

A total of 5896 participants were included in the final analysis and 62.8% were females. The BMI of the participants was 25.4 ± 5.8 kg/m2. Around 38.4% of the participants stopped practicing any physical activities during the confinement (P < 0.001), and 57.1% reported spending more than 2 h on social media (P < 0.001). There were no significant changes in smoking habits. Also, 30.9% reported an improvement in their eating habits compared with 24.8% reported worsening of their eating habits. Fast-food consumption decreased significantly in 48.8% of the study population. This direct/indirect exposure to COVID-19 was associated with an increased consumption of carbohydrates (OR = 1.09; 95% CI = 1.02-1.17; P = 0.01), egg (OR = 1.08; 95% CI = 1.02-1.16; P = 0.01), sugar (OR = 1.09; 95% CI = 1.02-1.16; P = 0.02), meat, and poultry (OR = 1.13; 95% CI = 1.06-1.20; P < 0.01). There was also associated increase in hours spent on watching television (OR = 1.07; 95% CI = 1.02-1.12; P < 0.01) and social media (OR = 1.09; 95% CI = 1.01-1.18; P = 0.03). However, our results showed a reduction in sleeping hours among those exposed to COVID-19 infection (OR = 0.85; 95% CI = 0.77-0.94; P < 0.01).

CONCLUSIONS

The COVID-19 pandemic was associated with an increase in food consumption and sedentary life. Being exposed to COVID-19 by direct infection or through an infected household is a significant predictor of amplifying these changes. Public health interventions are needed to address healthy lifestyle behaviors during and after the COVID-19 pandemic.

Gastric perforation mimicking ST-segment elevation myocardial infarction

ST-elevation myocardial infarction (STEMI) is one of the medical emergencies in cardiology with high morbidity and mortality rate which requires rapid response. In elderly patients, its presenting symptoms may be atypical which may cause the diagnosis of MI to be delayed or missed. Therefore, ST-segment elevation on ECG has become the main instrument for initial diagnosis. However, there are a variety of conditions mimicking the ECG changes of STEMI. We report a case of 70-year-old patient with acute peritonitis and pneumoperitoneum secondary to gastric perforation with dynamic ECG changes mimicking anteroseptal STEMI. After the surgery, the ECG dynamically reverted to normal. He was then discharged after 4 days without any remaining symptoms. Misinterpretation of ECG findings may lead to unnecessary aggressive intervention, costly management strategies and delay in appropriate treatment.

Association of Acute Pancreatitis and Myocardial Infarction: Is the Heart Victim or Culprit? - A Case Report and Review of the Literature

Acute pancreatitis can be associated with electrical changes mimicking acute coronary syndrome with normal coronary arteries. The association of acute pancreatitis with ST-segment elevation and elevated cardiac enzymes has been reported in few observations. The pathophysiological mechanisms of this association remain poorly understood. We report the case of a 63-year-old woman presenting with chest pain, changes in the electrocardiogram and elevated cardiac enzymes with normal coronary arteries associated with acute pancreatitis. Stress cardiomyopathy or Takotsubo syndrome associated with acute pancreatitis was the most likely diagnosis in our case. Stress cardiomyopathy should be considered a possibility in case of patients with acute pancreatitis who present with clinical signs suggestive of acute coronary syndrome.