Giant J Waves and ST-Segment Elevation Associated With Acute Gastric Distension
A 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.
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).
The 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.1
The 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.4
The 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.
- © 2016 American Heart Association, Inc.
- Bonnemeier H,
- Mäuser W,
- Schunkert H
- Birse DR