Saint Louis University School of Medicine St. Louis, MO
Soumojit Ghosh, MD, Samuel Burton, MD, Elizabeth Marsicano, MD; Saint Louis University School of Medicine, St. Louis, MO
Introduction: The hallmark symptoms of heart failure (HF)include dyspnea, orthopnea, decreased exercise tolerance,and lower extremity swelling. Although abdominal symptoms such as pain and bloating can besymptoms of HF due to bowel wall edema, it is rare that these are the presenting symptoms.We report an interesting case of abdominal pain and bloating as the presenting symptoms of HF in a young patient.
Methods: A 37-year-old male was referred toGI by his PCP for evaluation of a 2-month history of progressive lower abdominal pain and a few episodes of melena. He endorsed moderate alcohol use and had a 20-pack-year smoking history. On exam, he was noted to have trace edema and mild abdominal tenderness to palpation. Labs were significant for normal CBC and elevated liver enzymes (LFTs) (AST 47 IU/L, ALT 152 IU/L). Esophagogastroduodenoscopy was done and revealed patchy gastric erythema and a non-bleeding gastric ulcer. Biopsy was negative for H. pylori. He was prescribed a PPI and was scheduled to follow-up in GI clinic for possible functional abdominal pain. One month later, he presented to the ED with worsening abdominal pain. On exam, he had 2+ pitting edema bilaterally and abdominal tenderness to palpation. Labs again revealed elevated LFTs (AST 55 IU/L, ALT 129 IU/L). A CT abdomen/pelvis incidentally revealed cardiomegaly with left ventricular (LV) dilatation [figure A] and a filling defect, concerning for an LV thrombus [figure B]. An echocardiogram confirmed an LV thrombus and an ejection fraction of 10-15% [figure C]. After IV diuresis and heparin drip, he had excellent clinical response with net negative 6L in first 48 hours. On discharge, he was scheduled for cardiology follow up. Discussion: Decompensated heart failure can lead to abdominal pain with the sensation of distention and bloating due to bowel wall edema and congestion. It has been shown that adolescent patients diagnosed with HF will commonly present with abdominal pain as their primary symptom. In contrast, in the adult population, although abdominal pain is a common symptom of pre-existing HF, it is rarely the presenting symptom. This rarity can lead to delayed diagnosis and treatment of HFif is not in the differential for abdominal pain. Furthermore, it is thought that these symptoms, such as abdominal pain, occur in the setting of severe HF, as seen in this case. Our case demonstrates the importance to consider advanced HF in the adult population if they present with abdominal pain of unknown origin.
Figure A: Upper limit of CT abdomen pelvis revealing dilated left ventricle
Figure B: CT abdomen/pelvis revealing left ventricular filling defect
Figure C: Echocardiogram confirming left ventricular filling defect
Disclosures: Soumojit Ghosh indicated no relevant financial relationships. Samuel Burton indicated no relevant financial relationships. Elizabeth Marsicano indicated no relevant financial relationships.