Critical Care and Shock

Perforated Pre-pyloric Ulcer Presenting with ST elevation on EKG

A 66 year-old female with long-standing history of rheumatoid arthritis on chronic steroid therapy, presented for routine kyphoplasty for a compression fracture of L1 and L2. Pre-operative electrocardiogram (EKG) revealed a normal sinus rhythm and no abnormalities. Her intra-operative course was complicated by severe hypotension. A post operative EKG revealed ST elevation in inferior and lateral leads with ST changes. She underwent a left heart catheterization that revealed normal coronary arteries and an ejection fraction of 70%. Because of concomitant abdominal discomfort, a computed tomography of abdomen was obtained and revealed a perforated viscus.

The patient underwent exploratory laparotomy, and was found to have perforated pre-pyloric ulcer for which she underwent surgical correction. Her postoperative course was complicated by multi-organ system failure (APACHE II score of 26). She was started on exogenous activated protein C and had a remarkable improvement with normalization of blood pressure, renal function and successful weaning from the mechanical ventilator. EKG changes mimicking acute myocardial infarction have been reported in patients with perforated bowel, pancreatitis, and other acute abdominal pathologies. Clinicians caring for patients with abnormal EKGs must be vigilant for conditions other than heart-related for such abnormalities.

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