Published online: Sep embe 20, 2020
Jou nal o Molecula and Clinical Medicine
J. Mol. Clin. Med. 2020 ol. 3(3), 87–90
©2020 Sal ado -Casabón e al. Published by IMR P ess.
Case Repo
Ca diac ex insic comp ession due o abdominal dis ension
as a cause o elec oca diog aphic abno mali y in a
c i ically ill pa ien
Juan Manuel Sal ado -Casabón1, Ja ie Esco a-Villanue a1, Paola Casano a-Es eban1, Ramón O iz-Giménez2,
Daniel Can e o-Lozano1and Juana Ma ía Peleg ín-Diaz1,∗
1Ca diology depa men , Hospi al Clínico Uni e si a io “Lozano Blesa”, Za agoza, Spain
2Radiology depa men , Hospi al Clínico Uni e si a io “Lozano Blesa”, Za agoza, Spain
*Co espondence: [email p o ec ed] (Juan Manuel Sal ado -Casabón)
DOI:10.31083/j.jmcm.2020.03.826
This is an open access a icle unde he CC BY 4.0 license (h ps://c ea i ecommons.o g/licenses/by/4.0/).
Anomalies in he ST segmen , especially ST-segmen ele-
a ion, equi e he uling ou o possible e iologies such as
myoca dial ischemia o pe ica di is. Howe e , o he non-
ca diac diso de s such as inc eases in in a-abdominal
and in a ho acic p essu e, may cause ST-segmen ele a-
ion as well and should be conside ed as possible e iolo-
gies due o he poo p ognosis hey imply in he clinical
e olu ion o he pa ien . This is especially impo an in c i -
ically ill pa ien s. In his espec , we he ein p esen a case
in which he inc ease in in a-abdominal p essu e and ho-
acic ca i y ele a ion due o gas ic and in es inal dis en-
sion, which was no p esen in he i s CT, p o oked a
ca diac and co ona y comp ession esul ing in T-shaped
dome wa e, a QT p olonga ion and ST segmen ele a ion
in he in e io leads o he elec oca diog am, he pa ien
did no p esen a he ime o admission, uling ou o he
possible e iologies such as ionic imbalance o acu e is-
chemia.
Keywo ds
Abno mal elec oca diog am; ST segmen ele a ion; QT p olonga ion;
Spiked Helme sign; abdominal dis ension
1. In oduc ion
The elec oca diog am is an impo an ool o diagnosing dis-
eases ha cause epola iza ion abno mali ies, mainly ischemic
hea disease. This is pa icula ly impo an in hose wi h ST ele-
a ion. Howe e , in he c i ically ill pa ien s, changes in epola -
iza ion (including ST ele a ion) ha e a low speci ici y due o he
a ie y o non-ischemic p ocesses ha can al e he elec oca dio-
g am and ha mus be aken in o accoun [1].
Ou p esen case illus a es ha se e e gas ic and bowel dis-
ension seconda y o pa aly ic ileus caused a displacemen o he
hea and comp ession o he pos e io descending a e y (PDA).
This led o a T-shaped dome wa e, QT p olonga ion and ST seg-
men ele a ion in he in e io leads o he elec oca diog am ha
was no ini ially p esen .
2. Case Repo
An 81-yea -old male, wi h a pas his o y o hype ension,
pa oxysmal a ial lu e and an episode o low diges i e hemo -
hage due o di e iculosis in Ap il 2018.
He wen o he eme gency depa men in Decembe 2018 due
o a new episode o low diges i e hemo hage due o di e icu-
losis ha caused hemodynamic ins abili y (blood p essu e 80/55
mmHg, Hb 7.3 g/dL). An u gen abdominal compu ed omog aphy
scan (CT) was pe o med e ealing ac i e bleeding in he descend-
ing colon. A su gical sub o al colec omy was pe o med wi h ileo-
colic mechanical anas omosis. Blood ans usions we e also pe -
o med and he hemoglobin le els and blood p essu e we e co -
ec ed. A e su ge y, he pa ien p esen ed good clinical e olu ion
and was ans e ed o he loo uni . The elec oca diog am a ha
ime showed sinus hy hm wi h na ow QRS wi hou al e a ions in
epola iza ion (Fig. 1).
On he 7 h day a e he su gical in e en ion, he p esen ed ab-
dominal dis ension, hypo ension and es lessness. Ano he u gen
abdominal CT was pe o med which uled ou su u e dehiscence
bu showed signi ican gas ic and small bowel dis ension sugges-
i e o pos ope a i e pa aly ic ileus and ele a ion o he ho acic
ca i y seconda ily. I also showed pleu al e usion bu no pe i-
ca dial e usion. No signs o isk o acu e in es inal ischemia like
pneuma osis o in ahepa ic po al ein gas we e obse ed.
Absolu e die was p esc ibed and a nasogas ic ube was placed.
Due o dyspnea seconda ily o dis ension (oxygen sa u a ion o
87%), he pa ien equi ed non-in asi e mechanical en ila ion o
a ime.
Al hough he pa ien was wi hou ches pain o o he new symp-
oma ology an elec oca diog am was pe o med. The elec oca -
diog am showed QT p olonga ion wi h a T-shaped dome wa e wi h
ST segmen ele a ion in some QRS complexes o he in e io leads
(Fig. 2). Blood sample showed: po assium 4.7 mEq/l, magnesium
2.37 mg/dL, o al se um calcium 8.9 mg/dL and he es ionic pa-
ame e s we e in no mal ange. In addi ion, he pa ien had no
ele a ion o bioma ke s o myoca dial nec osis. The pa ien e-
cei ed an ibio ic ea men wi h Ce azimide, no an ibio ics ha
could cause QT p olonga ion we e used. In he ollowing hou s,
Fig. 1. Baseline elec oca diog am made a pa ien admission showing no epola iza ion abno mali ies.
Fig. 2. Elec oca diog am when p esen ing he gas ic dis ension showing QT p olonga ion and wide dome shaped T-wa e wi h he ST segmen
ele a ion in some complexes o he in e io leads.
pa ien oxygena ion imp o ed and i was possible o emo e he
en ila o y suppo , while he elec oca diog am pa e n was s ill
p esen .
The CT was e alued and compa ed o he p e ious CT pe -
o med a he ime o admission: i was obse ed ha he bowel and
gas ic dis ension seconda y o ileus no ini ially p esen , caused
a comp ession o he in e io wall and pos e io in e en icula
g oo e o he hea whe e he PDA and pos e io in e en icula
88 Sal ado -Casabón e al.
Fig. 3. CT scan ho ax-abdominal a pa ien admission (le ) and a week la e ( igh ). Se e e bowel and s omach dis ension a week a e admission
( igh images) no seen a pa ien admission (le ) ele a es he ho acic ca i y and comp esses pos e io descending a e y and pos e io in e en icula
ein. A: Axial iew. Righ image is an uppe le el han le image due o abdominal dis ension. B: Co onal iew. Pos e io descending a e y is obse ed
in wo sec ions. A he ime o admission he s omach was collapsed, a week la e signi ican dis ension was obse ed. C: Sagi al iew. Tho acic ca i y
ele a ion due o abdominal dis ension is obse ed.
ein a e loca ed. (Fig. 3A-C). The PDA and he in e en icula
ein displayed simila con as enhancemen because he a e ial
phase o bo h CT we e acqui ed o s udy abdominal ascula iza-
ion.
Clinical e olu ion was un a o able, as he pa ien showed no
imp o emen in in abdominal dis ension possibly igge ing non-
occlusi e in es inal ischemia in he ollowing hou s, so conse a-
i e managemen and pallia i e seda ion we e pe o med and as a
esul , he pa ien e en ually died in he ollowing days.
3. Discussion
We p esen an in equen case o elec oca diog aphic al e -
a ion o ST segmen , QT p olonga ion and T-shaped dome wa e,
possibly due o ex e nal hea and PDA comp ession because o
gas oin es inal dis ension, in a pa ien admi ed o he in ensi e
ca e uni o a cause un ela ed o acu e ca diological pa hology.
This ele a ion o he ho acic ca i y seconda y o he gas oin-
es inal dis ension was no p esen in he ini ial CT (as can be
seen compa ing le and igh Fig. 3A-C), so we hypo hesized ha
changes in he elec oca diog am a e seconda y o ha ex insic
Volume 3, Numbe 3, 2020 89
comp ession on pos e io epica dial essels no ini ially p esen .
This is he i s case in which he e is e idence o a pa ien wi h
a no mal elec oca diog am coinciding a CT wi h no dis ension
and one week la e he pa ien showed hese elec oca diog aphic
al e a ions coinciding wi h he p esence o an ele a ion o he ho-
acic ca i y and abdominal dis ension in he CT. He epo ed nei-
he ches no acu e epigas ic pain (he el bloa ing), in ac , he
elec oca diog am was pe o med by chance and no CT signs o
acu e non-occlusi e in es inal ischemia we e p esen . O he e i-
ologies ha could cause simila epola iza ion al e a ions such as
ionic imbalance o acu e myoca dial ischemia due o myoca dial
in a c ion, we e uled ou .
This a e al e a ion in dome-shaped epola iza ion, esembles
he "Spiked Helme sign" when his al e a ion coincides wi h he
QRS (because o i s simila i y o he mili a y helme o P ussia in
he mid-nine een h cen u y). This has been p e iously desc ibed
in some pa ien s, mainly in hose admi ed o an in ensi e ca e uni
[2]. Al hough he exac cause o he spiked helme ST ele a ion
is unce ain, he inc ease in bo h in abdominal and in a ho acic
p essu e seem o be ela ed o his cyclic elec oca diog aphic al-
e a ion [2,3,4,5]. This elec oca diog aphic pa e n has been
obse ed mo e equen ly in limb leads (II, III, aVF). I has also
been desc ibed in pa ien s connec ed o mechanical en ila ion
wi h equally high in a ho acic p essu es [4]. I has been pos u-
la ed ha he al e a ions in he in e io leads appea seconda y
o in a-abdominal p essu e inc eases o di e en easons while
hose wi h al e a ions in he p eco dial leads a e seconda y o in-
c eased in a ho acic p essu e such as pneumo ho ax [4,6].
This pa ien had an inc ease in bo h in a ho acic p essu e due
o mechanical en ila ion and in a-abdominal p essu e due o gas-
ic dis ension and ileus bu he elec oca diog aphic al e a ions
we e obse ed in he in e io leads. In addi ion, he CT showed an
ele a ion o he ho acic ca i y due o gas ic dis ension and he
pa e n was s ill p esen once he en ila o y suppo was emo ed.
Ou case esembles he one desc ibed by Singh e al. [7]. They
pos ula ed ha inc ease in in a-abdominal p essu e p o oked ex-
e nal comp ession o he in e io epica dial a e ies ( igh co o-
na y and pos e io descending a e ies) wi h ST-segmen ele a-
ion in he in e io leads bu co ona y a e ies wi hou obs uc i e
lesions wi h esolu ion o he ST-ele a ion by dec easing in a-
abdominal p essu e. As he PDA uns in he pos e io in e en-
icula g oo e he inc ease in in a-abdominal p essu e a ec s i
di ec ly as he hea se les on he diaph agm, hence ha could ex-
plain ha inc eases in in a-abdominal p essu e ha e impac in he
in e io leads o he elec oca diog am and no in o he s. How-
e e , as many imes he e is no ele a ion o ma ke s o myoca dial
nec osis, epe i i e epide mal s e ch ela ed wi h he inc ease o
p essu e has been p oposed as an unde lying mechanism, sugges -
ing ha he clinical signi icance o his pa e n is no o pe o m
a ca diac ca he e iza ion, bu ocus on a possible c i ical abdomi-
nal e en [6].O he sugges ed mechanisms a e: s imula ion o he
diaph agm by he le ph enic ne e o di ec s imula ion o he
in e io wall o he le en icle by he diaph agm [8,9].
The p esence o his o simila elec oca diog aphic pa e n
in he in e io leads has been desc ibed in some c i ically ill pa-
ien s who p esen an inc ease in in a-abdominal p essu e. The
CT shows an ele a ion o he ho acic ca i y ha in ol es he in e -
en icula g oo e o he hea and he PDA, which was no p esen
on he CT se en days be o e and ha coincides wi h he changes
in he elec oca diog am, so we hypo hesized his may be he un-
de lying mechanism o his al e a ion. I s ea ly ecogni ion as a
ma ke o se e i y would con ibu e o a be e cha ac e iza ion o
he pa ien and when making he apeu ic decisions since i s p es-
ence seems o be associa ed wi h a poo sho - e m p ognosis.
E hics App o al and Consen o Pa icipa e
This case epo was conduc ed unde he consen o he hos-
pi al and in acco dance wi h he Decla a ion o Helsinki.
Acknowledmen s
We'd like o exp ess ou g a i ude o edi o s and pee e iew-
e s o hei opinions and sugges ions, which helped us du ing he
w i ing o his manusc ip .
Con lic o in e es
The au ho s decla e no con lic s o in e es s a emen
Re ised: Augus 26, 2020
Accep ed: Sep embe 12, 2020
Published: Sep embe 20, 2020
Re e ences
[1] Rennyson SL, Hun J, Haley MW, No on HJ, Li mann L. Elec o-
ca diog aphic ST-segmen ele a ion myoca dial in a c ion in c i i-
cally ill pa ien s: an obse a ional coho analysis. C i Ca e Med.
2010; 38(12): 2304-2309.
[2] Li mann L, Mon oe MH. The "spiked helme " sign: a new elec o-
ca diog aphic ma ke o c i ical illness and high isk o dea h. Mayo
Clin P oc. 2011; 86(12): 1245-1246.
[3] Tomcsányi J, F ész T, P oc o P, Li mann L. Eme gence and esolu-
ion o he elec oca diog aphic spiked helme sign in acu e nonca -
diac condi ions. Am J Eme g Med. 2015; 33(1): e5-7.
[4] Li mann L, P oc o P. Real ime ecogni ion o he elec oca dio-
g aphic "spiked helme " sign in a c i ically ill pa ien wi h pneumo h-
o ax. In J Ca diol. 2014; 173(3): e51-e52.
[5] Hibbs J, O landi Q, Oli a i MT, Dickey W, Sha key SW. Gian J
Wa es and ST-Segmen Ele a ion Associa ed wi h Acu e Gas ic
Dis ension. Ci cula ion. 2016; 133(11): 1132-1134.
[6] Li mann L. Spiked helme pa e n ST ele a ion due o se e e ab-
dominal dis ension. J Elec oca diol. 2018;51(2):276-277.
[7] Singh M, Sood A, Rehman MU, O hman M, A onso L. Ele a ed
Hemi-diaph agms as a Cause o ST-segmen Ele a ion: A case epo
and e iew o li e a u e. J Elec oca diol. 2017; 50(5): 681-685.
[8] B ea ley WD J , Taylo L 3 d, Haley MW, Li mann L. Pneumome-
dias inum mimicking acu e ST-segmen ele a ion myoca dial in a c-
ion. In J Ca diol. 2007; 117(2): e73-e75.
[9] Chase C, B ady WJ. A i ac ual elec oca diog aphic change mim-
icking clinical abno mali y on he ECG. Am J Eme g Med. 2000;
18(3): 312-316.
90 Sal ado -Casabón e al.
