No small dilemma: small bowel volvulus mimicking acute coronary syndrome

Abstract

Acute abdominal pathologies can cause electrocardiogram (ECG) changes mimicking an acute coronary syndrome (ACS), resulting in diagnostic uncertainty and delay. We report a 65-year-old male with multiple risk factors for ACS who presented with four hours of progressive epigastric and chest pain that resolved in the emergency department. ECG findings were concerning for new deeply inverted T-waves with normal troponins, raising concerns for Wellens Syndrome. Emergent heart catheterization was negative but abdominal computed tomography angiography showed occlusion of the superior mesenteric vessels. Subsequent exploratory laparotomy revealed a small bowel volvulus with extensive necrosis, resulting in a 430 cm resection.

Keywords: Wellens syndrome; abdominal pain; acute coronary syndrome; bowel necrosis; mesenteric ischemia; volvulus.

Figure 1

ECG taken en route to the Emergency Department showing ST elevation in the anterior-lateral leads.

Figure 2

ECG in the Emergency Department revealing an accelerated junctional rhythm with minimal ST elevation in V3, and new deeply inverted T waves in V2-V4 consistent with Wellen’s T’s, concerning for ischemic changes.

Figure 3

Computed tomography angiography of the abdomen with areas of “swirls” (white arrows) concerning for volvulus. A, axial and B, coronal views.