A4 1-year-old man was admitted to the hospital because of severe lower sternal pain with diaphoresis for 1 hour. He had no history of peptic ulcer disease and denied smoking, alcohol abuse, and use of illicit drugs. An ECG (Figure 1⇓) revealed ST-segment elevation of 2 mm and peaked upright T waves in leads V1 through V3, with reciprocal changes in lead II and inverted T waves in V4 through V6. Particular noteworthy were the bizarre T waves observed in the limb leads. Cardiac enzymes, liver function tests, and serum electrolytes, amylase, and lipase were within normal limits. A diagnosis of acute myocardial infarction was suspected. Thrombolytic therapy was considered but was rejected by the patient. Intravenous nitroglycerin, heparin, and β-blocker were administered but did not ameliorate his symptoms.
An echocardiogram showed no wall motion abnormalities. Serial cardiac enzymes were normal. A contrast-enhanced CT scan (Figure 2⇓) and MRI (Figure 3⇓) of the abdomen 1 day after admission, however, disclosed diffuse swelling of the pancreas and associated mesenteric venous thrombosis (arrow, a low-density thrombus in the portal vein). A 3-fold elevation of serum lipase was noted on hospital day 5. The patient received nothing by mouth and was supported with intravenous fluids and adequate analgesia. Anticoagulation therapy was continued for his venous thrombosis. He recovered in 2 weeks, and there was gradual resolution of the ECG ST-segment elevation toward baseline and normalization of the T waves.
ECG changes resembling acute myocardial infarction are a rare phenomenon in acute pancreatitis. The ECG changes probably reflect changes in the vagal nervous system. Visceral venous thrombosis is also a rare but potentially lethal complication of acute pancreatitis. The initial cardiovascular manifestations in this patient gave the misleading impression of acute myocardial infarction.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
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