i An update to this article is included at the end

Pancreatic cholangiocarcinoma as an ST-e”>American Journal of Emergency Medicine (2010) 28, 389.e3-389.e5

Case Report

Pancreatic cholangiocarcinoma as an ST-elevation myocardial infarction with thrombolytic therapy

Abstract

We report the case of a 46-year-old patient who presented a chest pain with ST-segment elevation in precordial leads V1 (2 mm), V2 (4 mm), and V3 (3 mm). Thrombolytic therapy was initiated with the combination tenecteplase tissue plasminogene activator, aspirin, and heparin. Further electrocardiogram and cardiac enzymes measured every 2 hours during the first 24 hours remained normal, and after a computed tomography of the abdomen, the patient was taken to surgery for an exploratory abdominal operation that revealed pancreatic cholangiocarcinoma. No adverse effects were attributed to the initial thrombolytic therapy. Finally, myocardial ischemia was excluded because the electrocar- diogram, cardiac enzymes, and a 1-month later cardiac stress test remained normal and because no coronary event occurred during the first year after surgery. Our case shows that it is sometimes difficult to make the share, in prehospital field, between coronary syndrome and other pathology, particularly digestive pathology. However, in the appropriate chest pain patient with presumed acute myocardial infarc- tion, ST-segment elevation remains the primary criterion for the initiation of thrombolytic therapy, primary angioplasty, and/or other pharmacologic interventions.

It is well known that cardiac ischemia from coronary insufficiency can present as digestive symptoms such as Epigastric pain or nausea and vomiting [1]. In contrast, hepatobiliary-pancreatic pathology does not commonly present as chest pain with electrocardiographic changes suggestive of coronary disease. We report a patient whose presentation of pancreatic disease had impressive coronary symptoms that were sufficient to lead to immediate Fibrinolytic therapy. This 46-year-old-man, white, with no history of medical problems noticed the first onset in his life of Retrosternal chest pain, as sudden squeezing pain combined with epigastric pain, without radiations. The pain

started after a moderate effort and was constant during all the time since the beginning 2 hours before; it was not modified by changing position. He had stopped smoking 6 months previously and had no other cardiovascular risk factor. The clinical examination was normal (including heart sounds, breath sounds, and Abdominal examination). The blood pressure was 140/90 mm Hg; heart rate, 80 beats/min (regular); the respiratory rate, 20 breaths/min; SpO2, 98 %; and tympanic temperature, 37.2?C. A 12-lead electrocardio- gram (ECG) showed ST-segment elevation in precordial leads V1 (2 mm), V2 (4 mm), and V3 (3 mm; Fig. 1). Informed consent was obtained and thrombolytic therapy was initiated with the combination of tenecteplase tissue plasminogene activator, aspirin, and heparin. The patient was admitted to the cardiology intensive care unit within 4 hours after the beginning of his pain. However, at the time of admission, he had epigastric pain only; his chest pain had disappeared. A second ECG was then performed (Fig. 2), and it showed resolution of the ST-segment elevation. Electrocardiogram and cardiac enzymes measured every 2 hours during the first 24 hours remained normal (troponin I, creatine kinase-MB). The following abnormal laboratory values were found: alkaline phosphatase was 3.5x normal; Gamma glutamyl transferase was 2.5x normal; there was mixed hyperbilirubinemia, the prothrombin time was 97%; the aspartate aminotransferase was 2.5x normal; the alanine aminotransferase was 3.5x normal; the white blood cell count was 15.2 G/L (or 15200 L). Two hours later, the patient began shivering, and his central temperature increased to 39?C. At that point, severe epigastric pain inhibited his breathing, without radiation.

Fibrinolytic therapy was then stopped. No coronary

arteriography was performed, and after a computed tomog- raphy of the abdomen, the patient was taken to surgery for an exploratory abdominal operation.

At surgery, a cephalic pancreatoduodenectomy revealed pancreatic cholangiocarcinoma. No adverse effects were attributed to the initial thrombolytic therapy. No complica- tion occurred during surgery.

Finally, myocardial ischemia was excluded because the ECG and cardiac enzymes remained normal (according to

0735-6757/$ – see front matter (C) 2010

389.e4 Case Report

Fig. 1 Electrocardiogram showing ST-segment elevation in precordial leads (V1, V2, and V3).

the joint publication [2] of the American College of Cardiology and the European Society of Cardiology), because a 1 month later cardiac stress test remained normal, and because no coronary event occurred during the first year after surgery.

Electrocardiographic changes in patients with acute pancreatitis and cholelithiasis are well known in the literature. These changes usually consist of T-wave inversion or ST-segment depression. ST-segment elevation without the presence of coronary artery disease is very rare in these circumstances [3]. Some similar cases were associated in the literature with inflammation diseases such as gangrenous appendix [4,5], perforated Duodenal ulcer [6], acute cholecystitis [7], and biliary disease [8]. Some authors [9,10] reported cases of patients with acute pancreatitis and who had ST-segment elevation suggesting an early stage of an acute myocardial infarction (MI). Three cases were associated with no inflammation process, including traumat-

ic pericardiodiaphragmatic rupture [11], intestinal obstruc- tion [12], and rectal sheath hematoma [13]. To our knowledge, only 1 case of Thrombolytic treatment was reported in a patient with acute cholecystitis without adverse effects [14]. Khoury et al [15] studied 609 consecutive patients who were treated with thrombolytic therapy for suspected MI. In 35 cases (5.7 %), MI was ruled out on the basis of persistently normal serum creatine kinase-MB isoenzym levels. In this consecutive series of patients in whom MI was ruled after thrombolysis, the authors found no demographic or presenting clinical features to distinguish them from patients in whom MI was diagnosed. Our case shows that it is sometimes difficult to make the share, in prehospital field, between coronary syndrome and other pathology, particularly digestive pathology. It is to our knowledge the first description of a pancreatic cholangio- carcinoma presenting as an ST-elevation MI. However, despite the incorrect application of a potentially dangerous

Fig. 2 Second ECG showing resolution of the ST-segment elevation.

Case Report 389.e5

therapy such as thrombolysis, no adverse effect was noted. In the appropriate chest pain patient with presumed acute MI, ST-segment elevation remains the primary criterion for the initiation of thrombolytic therapy, primary angioplasty, and/ or other pharmacologic interventions.

Baptiste Valle MD Philippe Frontin MD Vincent Bounes MD Charpentier Sandrine MD

SAMU 31, Pole de Medecine d’Urgence

Hopitaux Universitaires 31059 Toulouse cedex 9, France

E-mail address: [email protected]

Vincent Minville MD Pole d’Anesthesie – Reanimation Hopitaux Universitaires

31059 Toulouse cedex 9, France

Ducasse Jean-Louis MD

SAMU 31, Pole de Medecine d’Urgence

Hopitaux Universitaires 31059 Toulouse cedex 9, France

doi:10.1016/j.ajem.2009.07.027

References

1. Khairy P, Marsolais P. Pancreatitis with electrocardiographic changes mimicking acute myocardial infarction. Can J Gastroenterol 2001;15: 522-6.
2. Alpert JS, Thygesen K, Antman E, Bassand JP. Myocardial infarction redefined–a consensus document of the Joint European Society of Cardiology/American College of Cardiology Committee. J Am Coll Cardiol 2000;36:1507-13.
3. Krasna MJ, Flancbaum L. Electrocardiographic changes in cardiac patients with acute Gallbladder disease. Am Surg 1986;52:541-3.
4. Dewar C, Siddiqi A, Kayani J. Pseudomyocardial infarction associated with a retrocaecal gangrenous appendix. Emerg Med J 2002;19:481-2.
5. Wen-I L, Shih-Hung T, Shi-Jye C, Ching-Wang H, Yen-Yue L. Acute ruptured appendicitis and peritonitis with pseudomyocardial infarc- tion. Am J Emerg Med 2009;27:627.
6. Isaac J, Tekant Y, Kiong KC, et al. Laparoscopic repair of perforated duodenal ulcer. Gastrointest endosc 1994;40:68-9.
7. Terradellas JB, llot JF, Saris AB, et al. Acute and transient ST segment elevation during bacterial shock in seven patients without apparent heart disease. Chest 1982;81:444-8.
8. Antonelli D, Rosenfeld T. Variant angina induced by biliary colic. Br Heart J 1987;58:417-9.
9. Ryan ET, Pak P, DeSanctis RW. Brief report : myocardial infarction mimicked by acute cholecyctitis. Ann Intern Med 1992; 116:218-20.
10. Makaryus AN, Adedeji O, Ali SK. Acute pancreatitis presenting as acute inferior wall ST-segment elevations on electrocardiography. Am J Emerg Med 2008;26:734.
11. Barrett J, Satz W. Traumatic, pericardio-diaphragmatic rupture: an extremely rare cause of pericarditis. J Emerg Med 2006;30:141-5.
12. Mixon TA, Houck PD. intestinal obstruction mimicking acute myocardial infarction. Tex Heart Inst J 2003;30:155-7.
13. Cattermole GN, McKay N. Pseudo myocardial infarction. Emerg Med J 2006;23:e48.
14. Khoury NE, Borzak S, Gokli A, Havstad SL, Smith ST, Jones M. “Inadvertent” thrombolytic administration in patients without myo- cardial infarction: clinical features and outcomes. Ann Emerg Med 1996;28:289-93.
15. Brady WJ, Perron AD, Martin ML, Beagle C, Aufderheide TP. Cause of ST segment abnormality in ED chest pain patients. Am J Emerg Med 2001;19:25-8.

Update

American Journal of Emergency Medicine

Volume 28, Issue 8, October 2010, Page 980

DOI: https://doi.org/10.1016/j.ajem.2010.07.010

American Journal of Emergency Medicine (2010) 28, 980-981

Errata

In the article “Pancreatic cholangiocarcinoma as an ST-elevation myocardial infarction with thrombolytic therapy” in the

American Journal of Emergency Medicine 2010;28(3):389.e3-389.e5, there was an error in the byline. The Correct byline is: Baptiste Valle MD

Philippe Frontin MD Vincent Bounes MD Sandrine Charpentier MD

SAMU 31, Pole de Medecine d’Urgence Hopitaux Universitaires

31059 Toulouse cedex 9, France

E-mail address: [email protected]

Vincent Minville MD

Pole d’Anesthesie-Reanimation Hopitaux Universitaires

31059 Toulouse cedex 9, France

Jean-Louis Ducasse MD

SAMU 31, Pole de Medecine d’Urgence Hopitaux Universitaires

31059 Toulouse cedex 9, France

DOI of original article: 10.1016/j.ajem.2009.07.027 doi:10.1016/j.ajem.2010.07.010

In the article, “Spontaneous coronary artery dissection in a Postpartum woman presenting with chest pain” Am J Emerg Med 2010; 28(5):641.e5-641.e7, there was an error in order of the byline. The correct byline is:

Leo Marcoff MD Andra Popescu MD Section of Cardiology

Department of Medicine Christiana Care Health System Newark, DE 19718

E-mail address: [email protected]

Letitia Price MD Department of Medicine Temple University Hospital Philadelphia, PA 19140

0735-6757/$ – see front matter (C) 2010