Cardiac Tamponade Masquerading as Gastritis: A Case Report
Cardiac Tamponade Masquerading as Gastritis: A Case Report
In our patient, the vague presentation of abdominal pain was mimicking gastritis. A prompt physical examination and high index of suspicion had solved our dilemma, and potential sequels were prevented. We are writing this case to re-emphasize the importance of the physical examination in the field of medicine and to alert physicians about the unusual presentation of a common disease which can be overlooked.
A presumptive diagnosis of acute viral pericarditis leading to pericardial tamponade was established. Cardiac tamponade is a medical emergency. Timely diagnosis and intervention are important to prevent mortality.
Acute pericarditis is a clinical syndrome caused by inflammation of the pericardium and is associated with chest pain, a friction rub and characteristic electrocardiographic changes. Pericardial effusion is a fluid collection in the pericardial space; depending on the underlying etiology and rate of accumulation, the clinical presentations may range from being asymptomatic to a life-threatening scenario.
Large pericardial effusion may be found unexpectedly without significant elevation of intrapericardial pressure and is usually asymptomatic, whereas rapidly accumulating effusions may result in compressive physiology and hence tamponade, characterized by a progressive limitation of ventricular diastolic filling and a reduction in cardiac output.
Acute cardiac tamponade occurs within minutes, due to trauma and rupture of the heart or great vessels, resembling cardiogenic shock that requires urgent drainage. Subacute events, as in our patient, are usually less dramatic and occur over days to weeks and usually due to non-traumatic causes.
Although cardiac tamponade is considered a clinical diagnosis; findings like hypotension, tachycardia, elevated jugular venous pressure, and pulsus paradoxus, are known to have limited sensitivity and specificity. Every effort should be made to narrow the wide range of possible etiologies, especially in the acute life-threating tamponade, a variant of cardiogenic shock.
Large effusion may be associated with muffled heart sounds. Dullness to percussion and bronchial breathing below the left scapular angle is rarely appreciated (Ewart's sign). Sinus tachycardia and hypotension are signs of hemodynamic compromise. Tachycardia is usually absent in hypothyroid or uremic individuals. In advanced cases where pulseless electrical activity can occur and heroin, a scenario of cardiac arrest can be puzzling, where urgent tapping can be life-saving with effortless external chest compression efforts.
Careful examination of pulse may anticipate the presence of pulsus paradoxus, with more than 10mmHg drop in systolic pressure due to impairment of left ventricular filling by the displaced septum during right ventricular filling and consequent drop in systolic pressure, a phenomenon known as ventricular interdependence. Evaluation for pulsus paradoxus should always be performed during normal respiration because deep inspiration may render a false positive finding. Physicians should be aware of other conditions in which pulsus paradoxus may be present without cardiac tamponade as obstructive airway diseases, such as marked obesity, massive pulmonary embolism, profound hypovolemic shock, severe pectus excavatum, bilateral pleural effusion, right atrial mass, right ventricular myocardial infarction and tension pneumothorax. Pulsus paradoxus is not specific for cardiac tamponade. Pulsus paradoxus may be absent in the presence of dehydration and in conditions with raised ventricular diastolic pressures as chronic hypertension or coexisting atrial septa defect or significant aortic regurgitation.
Beck's triad describes the combination of venous distension, distant heart sounds and absolute or relative hypotension. Pericardial rub may be audible, particularly in inflammatory pericarditis and cardiac apical impulse could be reduced or absent.
The classic EKG finding in large effusions consists of low voltage tracing. Electrical alternans is a fairly specific sign of massive effusion. For cardiomegaly to be evident in chest radiography, a minimum of 200 to 250mL of fluid has to be accumulated in the pericardial sac. If possible, lateral chest films should be attempted to detect large effusions.
Cardiac tamponade is not an "all-or-none" occurrence, but rather a continuum of findings. Clinicians should correlate the echocardiographic signs of tamponade (right ventricle collapse, right atrium collapse, respiratory variation of the mitral and tricuspid flow, and inferior vena cava plethora) with the symptoms and signs in each tamponade case.
Discussion
In our patient, the vague presentation of abdominal pain was mimicking gastritis. A prompt physical examination and high index of suspicion had solved our dilemma, and potential sequels were prevented. We are writing this case to re-emphasize the importance of the physical examination in the field of medicine and to alert physicians about the unusual presentation of a common disease which can be overlooked.
A presumptive diagnosis of acute viral pericarditis leading to pericardial tamponade was established. Cardiac tamponade is a medical emergency. Timely diagnosis and intervention are important to prevent mortality.
Acute pericarditis is a clinical syndrome caused by inflammation of the pericardium and is associated with chest pain, a friction rub and characteristic electrocardiographic changes. Pericardial effusion is a fluid collection in the pericardial space; depending on the underlying etiology and rate of accumulation, the clinical presentations may range from being asymptomatic to a life-threatening scenario.
Large pericardial effusion may be found unexpectedly without significant elevation of intrapericardial pressure and is usually asymptomatic, whereas rapidly accumulating effusions may result in compressive physiology and hence tamponade, characterized by a progressive limitation of ventricular diastolic filling and a reduction in cardiac output.
Acute cardiac tamponade occurs within minutes, due to trauma and rupture of the heart or great vessels, resembling cardiogenic shock that requires urgent drainage. Subacute events, as in our patient, are usually less dramatic and occur over days to weeks and usually due to non-traumatic causes.
Although cardiac tamponade is considered a clinical diagnosis; findings like hypotension, tachycardia, elevated jugular venous pressure, and pulsus paradoxus, are known to have limited sensitivity and specificity. Every effort should be made to narrow the wide range of possible etiologies, especially in the acute life-threating tamponade, a variant of cardiogenic shock.
Large effusion may be associated with muffled heart sounds. Dullness to percussion and bronchial breathing below the left scapular angle is rarely appreciated (Ewart's sign). Sinus tachycardia and hypotension are signs of hemodynamic compromise. Tachycardia is usually absent in hypothyroid or uremic individuals. In advanced cases where pulseless electrical activity can occur and heroin, a scenario of cardiac arrest can be puzzling, where urgent tapping can be life-saving with effortless external chest compression efforts.
Careful examination of pulse may anticipate the presence of pulsus paradoxus, with more than 10mmHg drop in systolic pressure due to impairment of left ventricular filling by the displaced septum during right ventricular filling and consequent drop in systolic pressure, a phenomenon known as ventricular interdependence. Evaluation for pulsus paradoxus should always be performed during normal respiration because deep inspiration may render a false positive finding. Physicians should be aware of other conditions in which pulsus paradoxus may be present without cardiac tamponade as obstructive airway diseases, such as marked obesity, massive pulmonary embolism, profound hypovolemic shock, severe pectus excavatum, bilateral pleural effusion, right atrial mass, right ventricular myocardial infarction and tension pneumothorax. Pulsus paradoxus is not specific for cardiac tamponade. Pulsus paradoxus may be absent in the presence of dehydration and in conditions with raised ventricular diastolic pressures as chronic hypertension or coexisting atrial septa defect or significant aortic regurgitation.
Beck's triad describes the combination of venous distension, distant heart sounds and absolute or relative hypotension. Pericardial rub may be audible, particularly in inflammatory pericarditis and cardiac apical impulse could be reduced or absent.
The classic EKG finding in large effusions consists of low voltage tracing. Electrical alternans is a fairly specific sign of massive effusion. For cardiomegaly to be evident in chest radiography, a minimum of 200 to 250mL of fluid has to be accumulated in the pericardial sac. If possible, lateral chest films should be attempted to detect large effusions.
Cardiac tamponade is not an "all-or-none" occurrence, but rather a continuum of findings. Clinicians should correlate the echocardiographic signs of tamponade (right ventricle collapse, right atrium collapse, respiratory variation of the mitral and tricuspid flow, and inferior vena cava plethora) with the symptoms and signs in each tamponade case.