Acute MI Which Presented with RLQ Abdominal Pain



81 yo AAF with PMH of HTN, DM2, CAD S/P MI 5 yrs ago, and chronic abdominal pain for 2 years w/o a clear reason was admitted to the hospital with a worsening of the same abdominal pain for 2-3 days.

No CP or SOB. She c/o nausea and vomiting.

Physical examination:
38.8-16-78-210/100
Abdomen: RLQ tenderness, no rebound, soft, +BS
The rest of the exam was not remarkable.

What labs to order?
CBCD, CMP, Amylase, Lipase, UA were all normal.
KUB was nonspecific.
CT of abdomen showed a dilated stomach, stable 3.6 cm AAA (the same size as 2 yrs ago) and old renal cysts.

Patient was started on IVF, pain meds and Zosyn for T* 38.3. Blood cx were taken.

What is your diagnosis?
Diverticulitis?
Appendicitis (no, appendectomy was done years ago)
DM Gastroparesis?
Gastroenteritis?

Do not make the list too long. One experienced internist once said that a long list of differentials is simply a list of wrong diagnoses (Adnan Tahir, MD).

What happened?
EKG on admission showed deep Qs in the inferior leads - probably an old MI. CPP x 1 was ordered.



EKG-before the MI; Second EKG showing acute changes of NSTEMI


CPP was positive, showing troponin elevation


Final diagnosis:
Non-STEMI

The catheterization showed a 99% occlusion of one of the branches of the Cx artery. Two stents were placed. RCA had 90% proximal stenosis but both stent placement and PTCA were unsuccessful. The patient was scheduled for a repeated catheterization for stent placement in RCA within 2-3 weeks.



The cardiologist drew a diagram of the stent placement in the Cx artery

What did we learn from this case?
Always keep the possibility of an AMI in patients with risk factors, even with atypical symptoms.
MI can be completely painless in diabetics and women.
You do not need CP to diagnose an MI.

Is it true that there is a "cardioptosis of old age"?
It means that with age the heart migrates down towards the abdomen. Consequently you have to rule out MI even in patients with abdominal pain.
No, not really. This is a just a lame cardilogy joke...

In this case though, the RLQ pain was not related to the MI.