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Poster Number: 545
LAPORAN PENGANJURAN SEMINAR KEPENDUDUKAN NEGERI SELANGOR 2024 (SKNS 2024)
NSTEMI; A POST-ERCP PANCREATITIS MIMIC

Authors: Zulkifli B. Abas, Aleena A., Tanaraj G., Nasri M., Muhaimin, Hudzaifah, Siau Y.S.
Affiliations: Department of Medicine, Hospital Putrajaya
Introduction

Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis is the most common
complication post-ERCP with a reported incidence of 3.47% and an associated mortality of 3.08%. It is
characterised by new or worsening abdominal pain and an amylase ≥3 times the upper limit of normal at
≥24 hours after ERCP. Prior studies have shown an association between pancreatitis and
electrocardiogram (ECG) abnormalities in up to 50% of patients in the form of non-specific ST-T
changes, diffuse T-wave inversions or ST-segment elevation. The occurrence of peri-procedural
myocardial ischemia with ERCP has also been documented, but its significance remains controversial.
We report a case of a gentleman who presented with epigastric pain and was eventually diagnosed with
Non-ST Elevation Myocardial Infarction (NSTEMI).

Case Summary

A 60 year-old male with underlying type 2 diabetes mellitus, hypertension, hyperlipidaemia who was an
ex-smoker. Included in his pre-morbids was choledocholithiasis with a dilated biliary tree in which he had
undergone an ERCP less than a week prior to admission. Post-ERCP, he presented with worsening
breathlessness for 3 days and had prickling epigastric pain, worsening 24 hours prior to admission. Pain
started radiating his whole chest and associated with diaphoresis. Upon initial presentation he was
normotensive but was tachycardic, tachypneic with an oxygen saturation of 82% under room air with lung
findings of bibasal crepitations. His ECG showed sinus tachycardia (HR 111), left ventricular hypertrophy
and ST depressions over leads V5-V6; similar to his baseline. His initial blood investigations were
unremarkable other than a mildly raised Troponin I 33.3 (N <11.6), serum amylase of 400, urine amylase
of 582 & ALP of 382. Chest radiograph also showed fluid in fissure with Kerley b lines, no cardiomegaly.

He was initially treated for post-ERCP pancreatitis after seen by both medical and surgical teams.
However, in view of ongoing chest pain his Troponin I was repeated which demonstrated a considerable
spike to 13792. The case was then discussed with IJN cardiologist oncall for urgent cardiac workup and
intervention. He was then transferred to IJN for coronary angiogram which revealed severe 3VD with LMS
involvement. Viability study also showed a moderate area of non-transmural infarcted myocardial
segments in the RCA/LCx territories. Eventually, the patient underwent coronary artery bypass graft and
planned for routine appointment at IJN.

Figure 1: LMS: Figure 2: Figure 3:
mild to LAD: RCA: Ectatic,
moderate severe diffuse
disease, disease severe
tapering at ostial - disease,
distal, severe; proximal subtotal
LCx Diffuse stenosis
diesase, severe lower mid
disease segment
proximal,
severe OM
Figure 1,2,3: COROS images courtesy from Insitute Jantung Negara
Conclusion
This case illustrates the possible dilemma in differentiating between NSTEMI
and post-ERCP pancreatitis. Although the main complication post-ERCP
remains pancreatitis, it is important to consider the diagnosis of NSTEMI
especially in a patient who has risk factors for ischaemic heart disease.

Acknowledgement: We would like to thank the Director General Ministry of Health
Malaysia for the permission to present this abstract.

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