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Electrocardiographic changes in active duodenal and gall bladder disease
E LECTROCAR1)IOGRAPHIC Cti AN(IES IN A (N? [ VE I)l !0 !) ENAt AND GALl~ Bt~A1)DER DISI~ASF~ No~MaN I~L (:~,aR~E, M.D?~ DETRO~{T, i'~ICH o
n
GROWING literature attests the relationship between upper right abdominal disease and attacks of acute substernal pain which simulate angina peetoris or even coronary oeclusiono The subject has been presented recently by Miller ~ and Levy and Boas. 2 An aevurau~ differential diagnosis is essential, especially when surgical risk is involve& The pain of coronary occlusion is sometimes referred m the abdomen a~d resembles that of acute upper abdominal disease, i> such instances we rely heavily on the electrocardiogram in the differential diagnosis. Our aging population has produced a higher incidence of associated gaIi bladder and core-. nary disease, and, rarely, acute conditions in botL o(:cur simultaneously. The *ollowing reeords are of patients who had ae{ive gall bladder or duodenal disease; their acute attacks oi: pain were referred to the substerna! region and resembled angina pectoris or ~x~ronary oeetusi,~m. This type of patient presents a serious problem, and emphasizes the importunate of the g~astrointestiuaI tract in cardiology. ]t is i~portant that ~be electrocardiographic changes which are fom~d in the presence of these diseases be noI; misinte> preted. The electrocardiograms of these patients showed an ~musual alteration which may be important in the differential diagr~osis of acute duodenal or gall bladder disease and coronary ovcqusiOno e a 8 ~ REPORTS CASE 1.--Itistorg.--This 44-year-old ma~ h a d experienced vague abdomina~ distress for m a n y weeks, a n d h a d t a k e n soda to relieve upper a b d o m i n a l ai~d lower chest pressure° H~s acute illness occurred in April~ 1940o While r e m o v i n g his ear from the g a r a g e a f t e r break~ fast, he w a s seized w i t h severe b u r n i n g pai~ b e n e a t h his s t e r n u m which did not radiat% was m a d e worse b y m o v e m e n t , a n d lasted five minutes. He co~tinued w i t h his usual a e t i v ities d u r i n g the following f e w weeks~ and h~d severai similar bat less severe s u b s t e r n a l pai~s a f t e r exertion w h i c h were relieved b y testo While p e r f o r m i n g s t r e n u o u s a c t i v i t y he h a d a more severe a t t a c k of s u b s t e r n M pal~z which was accompanied by swe~ting~ mild nausea~ and prostration. This a t t a e k required morphine, and, d u r i n g the following night~ he was a w a k e n e d b y a m o s t severe a t t a c k of s~absternal pain~ witf~ nausea, v o m i t i n g , sweating, ~¢nd the appearance of shoek~ which aga-b~ required morphh~e ,%r reliefo Examination.--~e w a s seen t e n hours a~'ter his Just severe a t t a c k of pain, w a r n he -was free of s y m p t o m s . H i s pulse r a t e w a s 72~ i~.*~dhis blood pressure, 100/60o ~Phe pupil ~ary a n d t e n d o n reflexes were norton b and n o t h i n g u n u s u a l was noted in the ]ungso E x a m b n a t i o n of t h e h e a r t a n d blood vessels was **egative. Slight~ deep, epigastrie t e n d e r n e s s was noted. Flnoroseopie e x a m i n a t i o n of the chest a, f e w d a y s l a t e r showed n o t h i n g abnorma~ about the lungs or d i a p h r a g m , and the h e a r t a n d aorta, were of normal size axed shape. Electrocardiogram.--Fig. 1~ A, t a k e n May [0~ 1940, the d a y a f t e r his m o s t severe att a c k of s u b s t e r n a l pain, shows normal limb ]eads, but CR.~ shows aa isoeleetrie :R-T s e g m e n t and a p o s i t i v e - n e g a t i v e T way% the i n v e r t e d portion being deep ~md pointed, FAg. t., ]L t a k e n J u n e 10, 1940~ just; :prior to ulcer therapy~ b u t a f t e r f o u r weeks of res+~ in bed, shows the same, but less marked, changes in the ~P waves of Lead CIg,, [qg. 1~ C~ was taken Ouly 2, 1940~ after three weeks of t r e a t m e n t for the d*mdenal ulcer, a n t is normal iu all f o u r leads. Fig. 1, D, was t a k e n Nov. 3, 194:1. ~Phe stan(bt~d limb leads and ehes~; Leads CRy, :~,~,~ a~re ~mrmaI. Received for publication Sept. 13, 1944. *Department of Medicine, Providence Hospita.l, Detroit, M~eh~g~3rt. ~28
CLARKE
:
ELECTROCARDIOGRAM
IN
UPPER
ABDOMINAL
DISEASE
629
Treatme& and, Progress.-He was hospitalized in May, 19-10, after his last severe attack of substerna pain, and a few weeks later a gastrointestinal roentgenologic examination revealed: “Chronic duodenal ulcer, with associated irritability and spasm suggesting activity at this time.” He was placed on ulcer therapy June II, 1940. On July 2, B940, he was free from all symptoms, but in December, 1940, he noted a slight burning pain in the lower part of the right hemithorax, radiating up to the substernal region, which occurred following exertion after meals. On Nov. 3, 1943, he was free of symptoms. He had been working very hard since December, 1940, without dietary restrictions, and there had been no recurrence of the roentgenologic examination, but no evidence of activity.”
A.
Fig. l.-Diagnosis attack of chest pain; the B, was taken June 10, rest in bed, the diphasic 1940, after three weeks includes chest Leads (2-3
chest pains made Nov.
B.
or any ot,her symptoms. 4, 1943, showed ‘ 1 slight
c.
The upper gastrointestinal deformity of duodenal bull),
I).
: acute duodenal ulcer. A was taken May 10, 1940. after an acute limb leads are normal, and the T wave in CR* is plus-minus diphasic. 1940, just prior to starting ulcer therapy. but, after four weeks of T wave in Lead Clt, was less pronounced. C was taken July 2. of ulcer therap), and all leads are normal. D, taken Nov. 3, 1943, alld 5, and is entirely not‘mal.
CASE 2.-History.-This 47.year-old man had had “stomach trouble” for thirty years. l.:ating certain foods would cause flatulence, hyperaeidity, and vague abdominal distress. A gastrointestinal roentgenologic examination, done in 1936, showed “mild spasm of the pylorus, with a few retained flecks of barium in the first portion of the duodenum, but no filling defect. ” Appendectomy was performed at that time, and his abdominal symptoms were reIieved until March, 1940. During a iong walk he suddenly had severe pain which was squeezing in the precordial and lower sternal regions and radiated into the left arm. Standing still gave some relief, and he was able to continue on. to his home. On the following days he had similar pains which were less severe. While at rest in bed he had a very severe attack of pain in the chest which radiated into both arms, and the left arm continued to ache for several hours. There was no nausea or vomiting, but he sweat profusely and was dyspneie. The succeeding night he was awakened by a similar severe pain which spread over the entire anterior portion of the chest. Examination.-He was seen a few days after his last severe attack of pain, when he was free of symptoms. His resting pulse rate was 72, and his blood pressure was 130/90. The pupillary and tendon reflexes were normal, and examination of the fundi was negative. Both lungs were normal, and the heart was of normal size; its rhythm was regular, and the sounds were good, with no murmurs and normal accentuations at the base. There was slight tenderness deelj in the epigastrium, but no muscle spasm, and there were no paIpab?c
A.
B.
i:
Li
1
A. B. c. D. Fig. f.-Diagnosis : acute cholecystitis. a was taken May 9, 1940, and shows bradycardia. but otherwise is normal. R was taken Aug. 9, 1941, tw?lve hours after attack of severe substernah pain; the R-T segment is elevated in Lead I and depressed in Lead III; T1 shows pIus-minus, and T?. minus-plus inversion; in CR& the R-T segnlent is isoelectric an(l the T wave shows a plus-minus inversion. C was taken Aug. 13, 1941, and shows bradycardia and similar, but less pronounced, changes in the T waves of Leads I, III, and CR,. D. taken Nov. 23, 1943. is normal; the R wave in CR, which was tlrcrensed in thtl elnctrocardioararn of Sept. 25, 1941, has assumed its former amplitude. DISCI’SSIOK L >b
There are many conditions which tempomrily alter the elect~ocariliog~anl. Recently, Seherf, et a1.,3 have discussed electroeardio~raphic changes which f~orn duodenal uleem However, they oltthey attrihute to acute hemorrhage served that the electrocar.diographie changes were not alt,ered by transfusions. nor did they bear any relalioqship to the hemoglobin content of the p;ltients’ blood.
n
GROWING literature attests the relationship between upper right abdominal disease and attacks of acute substernal pain which simulate angina peetoris or even coronary oeclusiono The subject has been presented recently by Miller ~ and Levy and Boas. 2 An aevurau~ differential diagnosis is essential, especially when surgical risk is involve& The pain of coronary occlusion is sometimes referred m the abdomen a~d resembles that of acute upper abdominal disease, i> such instances we rely heavily on the electrocardiogram in the differential diagnosis. Our aging population has produced a higher incidence of associated gaIi bladder and core-. nary disease, and, rarely, acute conditions in botL o(:cur simultaneously. The *ollowing reeords are of patients who had ae{ive gall bladder or duodenal disease; their acute attacks oi: pain were referred to the substerna! region and resembled angina pectoris or ~x~ronary oeetusi,~m. This type of patient presents a serious problem, and emphasizes the importunate of the g~astrointestiuaI tract in cardiology. ]t is i~portant that ~be electrocardiographic changes which are fom~d in the presence of these diseases be noI; misinte> preted. The electrocardiograms of these patients showed an ~musual alteration which may be important in the differential diagr~osis of acute duodenal or gall bladder disease and coronary ovcqusiOno e a 8 ~ REPORTS CASE 1.--Itistorg.--This 44-year-old ma~ h a d experienced vague abdomina~ distress for m a n y weeks, a n d h a d t a k e n soda to relieve upper a b d o m i n a l ai~d lower chest pressure° H~s acute illness occurred in April~ 1940o While r e m o v i n g his ear from the g a r a g e a f t e r break~ fast, he w a s seized w i t h severe b u r n i n g pai~ b e n e a t h his s t e r n u m which did not radiat% was m a d e worse b y m o v e m e n t , a n d lasted five minutes. He co~tinued w i t h his usual a e t i v ities d u r i n g the following f e w weeks~ and h~d severai similar bat less severe s u b s t e r n a l pai~s a f t e r exertion w h i c h were relieved b y testo While p e r f o r m i n g s t r e n u o u s a c t i v i t y he h a d a more severe a t t a c k of s u b s t e r n M pal~z which was accompanied by swe~ting~ mild nausea~ and prostration. This a t t a e k required morphine, and, d u r i n g the following night~ he was a w a k e n e d b y a m o s t severe a t t a c k of s~absternal pain~ witf~ nausea, v o m i t i n g , sweating, ~¢nd the appearance of shoek~ which aga-b~ required morphh~e ,%r reliefo Examination.--~e w a s seen t e n hours a~'ter his Just severe a t t a c k of pain, w a r n he -was free of s y m p t o m s . H i s pulse r a t e w a s 72~ i~.*~dhis blood pressure, 100/60o ~Phe pupil ~ary a n d t e n d o n reflexes were norton b and n o t h i n g u n u s u a l was noted in the ]ungso E x a m b n a t i o n of t h e h e a r t a n d blood vessels was **egative. Slight~ deep, epigastrie t e n d e r n e s s was noted. Flnoroseopie e x a m i n a t i o n of the chest a, f e w d a y s l a t e r showed n o t h i n g abnorma~ about the lungs or d i a p h r a g m , and the h e a r t a n d aorta, were of normal size axed shape. Electrocardiogram.--Fig. 1~ A, t a k e n May [0~ 1940, the d a y a f t e r his m o s t severe att a c k of s u b s t e r n a l pain, shows normal limb ]eads, but CR.~ shows aa isoeleetrie :R-T s e g m e n t and a p o s i t i v e - n e g a t i v e T way% the i n v e r t e d portion being deep ~md pointed, FAg. t., ]L t a k e n J u n e 10, 1940~ just; :prior to ulcer therapy~ b u t a f t e r f o u r weeks of res+~ in bed, shows the same, but less marked, changes in the ~P waves of Lead CIg,, [qg. 1~ C~ was taken Ouly 2, 1940~ after three weeks of t r e a t m e n t for the d*mdenal ulcer, a n t is normal iu all f o u r leads. Fig. 1, D, was t a k e n Nov. 3, 194:1. ~Phe stan(bt~d limb leads and ehes~; Leads CRy, :~,~,~ a~re ~mrmaI. Received for publication Sept. 13, 1944. *Department of Medicine, Providence Hospita.l, Detroit, M~eh~g~3rt. ~28
CLARKE
:
ELECTROCARDIOGRAM
IN
UPPER
ABDOMINAL
DISEASE
629
Treatme& and, Progress.-He was hospitalized in May, 19-10, after his last severe attack of substerna pain, and a few weeks later a gastrointestinal roentgenologic examination revealed: “Chronic duodenal ulcer, with associated irritability and spasm suggesting activity at this time.” He was placed on ulcer therapy June II, 1940. On July 2, B940, he was free from all symptoms, but in December, 1940, he noted a slight burning pain in the lower part of the right hemithorax, radiating up to the substernal region, which occurred following exertion after meals. On Nov. 3, 1943, he was free of symptoms. He had been working very hard since December, 1940, without dietary restrictions, and there had been no recurrence of the roentgenologic examination, but no evidence of activity.”
A.
Fig. l.-Diagnosis attack of chest pain; the B, was taken June 10, rest in bed, the diphasic 1940, after three weeks includes chest Leads (2-3
chest pains made Nov.
B.
or any ot,her symptoms. 4, 1943, showed ‘ 1 slight
c.
The upper gastrointestinal deformity of duodenal bull),
I).
: acute duodenal ulcer. A was taken May 10, 1940. after an acute limb leads are normal, and the T wave in CR* is plus-minus diphasic. 1940, just prior to starting ulcer therapy. but, after four weeks of T wave in Lead Clt, was less pronounced. C was taken July 2. of ulcer therap), and all leads are normal. D, taken Nov. 3, 1943, alld 5, and is entirely not‘mal.
CASE 2.-History.-This 47.year-old man had had “stomach trouble” for thirty years. l.:ating certain foods would cause flatulence, hyperaeidity, and vague abdominal distress. A gastrointestinal roentgenologic examination, done in 1936, showed “mild spasm of the pylorus, with a few retained flecks of barium in the first portion of the duodenum, but no filling defect. ” Appendectomy was performed at that time, and his abdominal symptoms were reIieved until March, 1940. During a iong walk he suddenly had severe pain which was squeezing in the precordial and lower sternal regions and radiated into the left arm. Standing still gave some relief, and he was able to continue on. to his home. On the following days he had similar pains which were less severe. While at rest in bed he had a very severe attack of pain in the chest which radiated into both arms, and the left arm continued to ache for several hours. There was no nausea or vomiting, but he sweat profusely and was dyspneie. The succeeding night he was awakened by a similar severe pain which spread over the entire anterior portion of the chest. Examination.-He was seen a few days after his last severe attack of pain, when he was free of symptoms. His resting pulse rate was 72, and his blood pressure was 130/90. The pupillary and tendon reflexes were normal, and examination of the fundi was negative. Both lungs were normal, and the heart was of normal size; its rhythm was regular, and the sounds were good, with no murmurs and normal accentuations at the base. There was slight tenderness deelj in the epigastrium, but no muscle spasm, and there were no paIpab?c
A.
B.
i:
Li
1
A. B. c. D. Fig. f.-Diagnosis : acute cholecystitis. a was taken May 9, 1940, and shows bradycardia. but otherwise is normal. R was taken Aug. 9, 1941, tw?lve hours after attack of severe substernah pain; the R-T segment is elevated in Lead I and depressed in Lead III; T1 shows pIus-minus, and T?. minus-plus inversion; in CR& the R-T segnlent is isoelectric an(l the T wave shows a plus-minus inversion. C was taken Aug. 13, 1941, and shows bradycardia and similar, but less pronounced, changes in the T waves of Leads I, III, and CR,. D. taken Nov. 23, 1943. is normal; the R wave in CR, which was tlrcrensed in thtl elnctrocardioararn of Sept. 25, 1941, has assumed its former amplitude. DISCI’SSIOK L >b
There are many conditions which tempomrily alter the elect~ocariliog~anl. Recently, Seherf, et a1.,3 have discussed electroeardio~raphic changes which f~orn duodenal uleem However, they oltthey attrihute to acute hemorrhage served that the electrocar.diographie changes were not alt,ered by transfusions. nor did they bear any relalioqship to the hemoglobin content of the p;ltients’ blood.