Giant J Waves and ST-Segment Elevation Associated With Acute Gastric Distension
2016; Lippincott Williams & Wilkins; Volume: 133; Issue: 11 Linguagem: Inglês
10.1161/circulationaha.115.020607
ISSN1524-4539
AutoresJohn Hibbs, Quirino Orlandi, Maria Teresa Olivari, William Dickey, Scott W. Sharkey,
Tópico(s)Atrial Fibrillation Management and Outcomes
ResumoHomeCirculationVol. 133, No. 11Giant J Waves and ST-Segment Elevation Associated With Acute Gastric Distension Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBGiant J Waves and ST-Segment Elevation Associated With Acute Gastric Distension John Hibbs, BS, Quirino Orlandi, MD, Maria Teresa Olivari, MD, William Dickey, MD and Scott W. Sharkey, MD John HibbsJohn Hibbs From Allina Health, Abbott Northwestern Hospital, Minneapolis, MN (J.H., W.D.); and Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, MN (Q.O., M.T.O., S.W.S.). , Quirino OrlandiQuirino Orlandi From Allina Health, Abbott Northwestern Hospital, Minneapolis, MN (J.H., W.D.); and Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, MN (Q.O., M.T.O., S.W.S.). , Maria Teresa OlivariMaria Teresa Olivari From Allina Health, Abbott Northwestern Hospital, Minneapolis, MN (J.H., W.D.); and Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, MN (Q.O., M.T.O., S.W.S.). , William DickeyWilliam Dickey From Allina Health, Abbott Northwestern Hospital, Minneapolis, MN (J.H., W.D.); and Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, MN (Q.O., M.T.O., S.W.S.). and Scott W. SharkeyScott W. Sharkey From Allina Health, Abbott Northwestern Hospital, Minneapolis, MN (J.H., W.D.); and Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, MN (Q.O., M.T.O., S.W.S.). Originally published15 Mar 2016https://doi.org/10.1161/CIRCULATIONAHA.115.020607Circulation. 2016;133:1132–1134A 34-year-old woman was transferred to our institution because of suspected small-bowel obstruction and abnormal ECG.The patient presented to a rural hospital emergency department with progressive abdominal pain, nausea, and emesis that began 9 hours earlier. The patient had paraplegia with subsequent colostomy after a motor vehicle accident 17 years earlier.Initial evaluation revealed heart rate 99 beats/min, blood pressure 124/84 mm Hg, oxygen saturation 96%, temperature 36.8°C, and distended abdomen with hypoactive bowel sounds. Laboratory evaluation revealed hemoglobin 13.4 g/dL, white blood cell count 14 400/mm3, creatinine 0.48 mg/dL, sodium 135 mmol/L, potassium 3.7 mmol/L, carbon dioxide 28 mmol/L, chloride 94 mmol/L, anion gap 13 (normal, 5–18), calcium 10.3 mg/dL, magnesium 1.9 mg/dL, and amylase 48 IU/L.An initial ECG, 3 hours after admission, demonstrated sinus tachycardia and prominent J waves with inferolateral ST-segment elevation (Figure 1, Top). An abdominal computed tomography scan demonstrated possible small-bowel obstruction with marked gastric dilation (Figure 2). The patient refused a nasogastric tube and was treated with intravenous rehydration and antiemetic.Download figureDownload PowerPointFigure 1. Twelve-lead ECGs recorded on the day of admission. Top, The initial ECG recorded 3 hours after admission demonstrates sinus tachycardia with prominent J waves in leads 2, 3, aVF, and V4 through V6 with associated mild ST-segment elevation. Bottom, The second ECG recorded 12 hours after the initial ECG demonstrates sinus tachycardia and giant J waves with marked ST-segment elevation in leads 2, 3, aVF, and V4 through V6.Download figureDownload PowerPointFigure 2. Admission computed tomography of abdomen and pelvis without contrast. The stomach (white asterisk) is markedly distended with fluid. Also present are dilated fluid-filled small-bowel loops (white arrowheads).Because of progressive abdominal distension and the abnormal ECG, she was transferred to our institution 9 hours postadmission. Surgical consultation revealed severe ileus without mechanical bowel obstruction and a recommendation for conservative management. The patient again refused a nasogastric tube. A second ECG, on arrival at this institution, showed giant J waves with marked inferolateral ST-segment elevation (Figure 1, Bottom). Serial troponin I measurements were undetectable (<0.012 ng/mL). An echocardiogram demonstrated a hyperdynamic heart with an estimated ejection fraction of 65% to 70% and no pericardial effusion. A computed tomographic coronary angiogram showed normal coronary arteries with trace pericardial fluid and no pulmonary embolism.The patient improved with relief of symptoms and return of normal gastrointestinal motility; follow-up ECG showed complete disappearance of J waves and ST-segment elevation (Figure 3).Download figureDownload PowerPointFigure 3. Twelve-lead ECG after resolution of ileus. The ECG recorded 36 hours after the second ECG is normal with resolution of sinus tachycardia and disappearance of J waves and ST-segment elevation.DiscussionThe serial ECGs of this young woman demonstrated progressive and dramatic J waves with ST-segment elevation in the inferolateral leads in the setting of ileus and marked gastric distension with fluid. The second ECG resembled that of acute inferolateral myocardial infarction attributable to circumflex or right coronary artery obstruction. The ECG promptly returned to normal with ileus resolution. Evaluation demonstrated normal electrolytes and body temperature and no evidence for myocardial infarction, takotsubo cardiomyopathy, pericarditis, Brugada syndrome, or other conditions known to be associated with ST-segment elevation.1The ECG findings in this case are most consistent with the presence of giant J waves and associated ST-segment elevation. The J wave is an ECG deflection immediately after QRS termination, sometimes associated with ST-segment elevation, in which case it is generally referred to as the early repolarization pattern.2 The origin of the J wave is controversial and may represent either early repolarization or ventricular depolarization.3 The Osborn wave is a unique ECG finding also occurring at the end of the QRS complex, first described in the setting of hypothermia, but also seen in other settings such as hypercalcemia. Osborn waves may be dramatic but are not usually associated with elevation of the entire ST segment; therefore, we do not believe this case represents an example of giant Osborn waves.4The ECG abnormality in this patient involved the entire JT segment and likely represented a transient electrophysiological phenomenon, perhaps from a transient change in ion channel function. This pattern may occur with acute gastric distension with fluid.5 The progressive prominence of the J wave, especially in the inferior leads, together with the unusual appearance of the ST segment, distinguish this ECG pattern from that seen with acute coronary artery occlusion. These interesting ECG findings further expand the conditions associated with ST-segment elevation in the absence of acute myocardial infarction.DisclosuresNone.FootnotesCorrespondence to Scott W. Sharkey, MD, Minneapolis Heart Institute Foundation, 920 East 28th St, Suite 300, Minneapolis, MN 55387. E-mail [email protected]References1. Wang K, Asinger RW, Marriott HJ. ST-segment elevation in conditions other than acute myocardial infarction.N Engl J Med. 2003; 349:2128–2135. doi: 10.1056/NEJMra022580.CrossrefMedlineGoogle Scholar2. Antzelevitch C, Yan GX, Viskin S. Rationale for the use of the terms J-wave syndromes and early repolarization.J Am Coll Cardiol. 2011; 57:1587–1590. doi: 10.1016/j.jacc.2010.11.038.CrossrefMedlineGoogle Scholar3. Surawicz B, Macfarlane PW. Inappropriate and confusing electrocardiographic terms: J-wave syndromes and early repolarization.J Am Coll Cardiol. 2011; 57:1584–1586. doi: 10.1016/j.jacc.2010.11.040.CrossrefMedlineGoogle Scholar4. Bonnemeier H, Mäuser W, Schunkert H. Images in cardiovascular medicine. Brugada-like ECG pattern in severe hypothermia.Circulation. 2008; 118:977–978. doi: 10.1161/CIRCULATIONAHA.108.771329.LinkGoogle Scholar5. Birse DR. Inferolateral ST-segment elevation associated with a gastric variceal bleed and the use of a Minnesota tube.BMJ Case Rep. 2014; 2014:. doi: 10.1136/bcr-2013-202795.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Zhang J, Basrawala H, Patel S, Girn H, Eyvazian V, Wang L and Ostrzega E (2020) Gastrointestinal Distention Masquerading as ST-Segment Elevation Myocardial Infarction, JACC: Case Reports, 10.1016/j.jaccas.2020.02.016, 2:4, (604-610), Online publication date: 1-Apr-2020. Mărgulescu A, Rees E, Richley D, Thomas D and Smith D (2019) ST elevation in a patient with small bowel occlusion and gastric distension—What is the most likely explanation? A hypothesis generating case report, Journal of Electrocardiology, 10.1016/j.jelectrocard.2019.08.044, 57, (77-80), Online publication date: 1-Nov-2019. Smirnov D, Birjukov A, Ivanchenko R, Vaulina D and Korolkov A (2019) Case of combination of acute intestinal obstruction and acute myocardial infarction, Grekov's Bulletin of Surgery, 10.24884/0042-4625-2019-178-3-47-50, 178:3, (47-50) Garbett L, O'Conghaile S and Pillai P (2019) Inferolateral ST-segment elevation with use of Sengstaken-Blakemore tube for variceal bleeding during orthotopic liver transplantation, BMJ Case Reports, 10.1136/bcr-2018-228000, 12:5, (e228000), Online publication date: 14-May-2019. Littmann L (2018) Spiked helmet pattern ST elevation due to severe abdominal distension, Journal of Electrocardiology, 10.1016/j.jelectrocard.2017.10.007, 51:2, (276-277), Online publication date: 1-Mar-2018. Singh M, Sood A, Rehman M, Othman M and Afonso L (2017) Elevated Hemi-diaphragms as a Cause of ST-segment Elevation: A case report and review of literature, Journal of Electrocardiology, 10.1016/j.jelectrocard.2017.04.001, 50:5, (681-685), Online publication date: 1-Sep-2017. Sharkey S, Orlandi Q and Olivari M (2016) Response by Sharkey et al to Letter Regarding Article, "Giant J Waves and ST-Segment Elevation Associated With Acute Gastric Distension", Circulation, 134:8, (e111-e112), Online publication date: 23-Aug-2016.Littmann L (2016) Letter by Littmann Regarding Article, "Giant J Waves and ST-Segment Elevation Associated With Acute Gastric Distension", Circulation, 134:8, (e109-e110), Online publication date: 23-Aug-2016. March 15, 2016Vol 133, Issue 11 Advertisement Article InformationMetrics © 2016 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.115.020607PMID: 26976919 Originally publishedMarch 15, 2016 PDF download Advertisement SubjectsElectrocardiology (ECG)
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