S3595 Acute Upper Gastrointestinal Bleeding Masquerading as a Demand ST-segment Elevation Myocardial Infarction

Abstract

Introduction: Acute upper gastrointestinal bleeding (UGIB) is a medical emergency requiring a timely diagnosis with prompt intervention. Patient’s usually present with signs of hemorrhagic shock such as hematemesis/melena, tachycardia, and hypotension. Here, we report a patient with an unusual presentation of UGIB with ST-segment myocardial infarction (STEMI) before the development of conventional symptoms. Case Description/Methods: A 37-year-old male with alcohol use disorder was hospitalized in the medical intensive care unit (ICU) for acute on chronic liver failure, resolving circulatory shock, and acute kidney injury. He complained of retrosternal chest pain and nausea following extubation. He had no fever or cough; chest examination revealed no abnormal findings. Chest X-ray was unremarkable. EKG revealed acute ST elevation in leads II, III, and avF with reciprocal depressions in V2 and V3 (1A). A bedside echocardiogram revealed no focal wall motion abnormalities. Point-of-care ultrasound revealed a distended stomach filled with heterogeneous contents (1C). He was intubated for airway protection in the context of worsening encephalopathy. Intravenous fluid resuscitation was initiated given decreasing BP, and ST-segment changes resolved (1B). Upper GI endoscopy examination revealed clotted blood in the entire examined stomach with an adherent clot at the cardia. The patient underwent massive transfusion protocol with emergent percutaneous portal venography with gastric and esophageal variceal embolization. The next day, his cardiac enzymes normalized and he eventually received a liver transplant and was transferred out of the ICU. Discussion: UGIB complicating STEMI’s (secondary to CAD) are uncommon and can be associated with excess morbidity and mortality. However, patients with STEMI’s from UGIB are seldom reported. Patients with hemorrhagic shock are prone to developing some degree of subendocardial ischemia causing Type 2 NSTEMI’s. In rare instances, patients may develop STEMI due to severe ischemia of the myocardium in the context of hemorrhagic shock and concurrent vasopressor use for mixed circulatory shock. Though common practice to activate the cardiac catheterization lab reflexively to patients with chest pain, STEMI, and elevated cardiac enzymes, it is worth being mindful of the other rarer etiologies that may cloud the clinical picture. Clinicians need to be cognizant of unusual presentations of hemorrhagic shock secondary to GIB to avoid delay in diagnosis and to provide timely intervention.Figure 1.: (A) ST Elevation in II, III, avF with reciprocal ST depression in V1 and V2. (B) Resolved EKG, normal sinus rhythm, (C) Point-of-care ultrasound of stomach filled with heterogeneous contents, (D) UGI endoscopy showed stomach filled with blood, (E) Esophageal and gastric embolization.