Ioannis M Panayiotides, Christoforos Panagides and Evagoras Nikolaides
Introduction: New-onset left bundle branch block (LBBB) in the electrocardiogram (ECG) is considered to be a particularly serious condition, which requires prompt further evaluation for the exclusion of possible underlying myocardial ischemia. . Case presentation: A 76 year old female Caucasian patient presented with gradually worsening abdominal discomfort, accompanied by nausea and vomiting. Initial clinical and laboratory investigations were indicative of acute pancreatitis, which was confirmed with an abdomen ultrasonography. A routine ECG, which was performed in the second day of hospitalisation, identified new-onset LBBB morphology, which was not initially present. The possibility of a rate-dependent LBBB was immediately excluded, since no significant alteration of the heart rate was noted. Considering the fact that myocardial infarction among elderly female individuals may present with non-typical features, a serious diagnostic problem appeared. Since there were no echocardiographic or biochemical indications consistent with acute myocardial ischemia it was decided to continue the medical treatment without alterations. The transthoracic echocardiogram also excluded the presence of significant valve lesions or any abnormalities in the structure and function of the myocardium. An ECG was repeatedly performed on a daily basis, but the LBBB persisted until the patient was discharged, seven days after admission, with a diagnosis of acute idiopathic pancreatitis. About three weeks after discharge, a re-evaluation was arranged. The patient reported no symptoms, without any deterioration of functional status. Also, disappearance of LBBB pattern was noted on the ECG. A myocardial perfusion scintigraphy was also carried out, at both rest and stress, without evidence of infarction or inducible ischemia. Conclusion: Acute pancreatitis can present with several ECG abnormalities, but the presence of transient LBBB in this setting is not considered very common. In fact, most of the times it seems to be correlated with electrolyte disturbances. The case presented here is regarded unique since no electrolyte abnormalities were present and a longer duration was noted. The proposed explanation and pathogenetic mechanism of this clinical manifestation is transdiaphragmatic epicardial irritation secondary to acute pancreatitis. It remains to be established by repeated assessment of the patient, whether this intermittent finding is associated with poor long-term outcome.