An unusual and life-threatening cause of epigastric pain presenting to the general surgical team: a case report

Abstract

Ann R Coll Surg Engl 2010; 92:1 The referral of patients to the emergency general surgeons with epigastric pain occurs on an almost daily basis. There are many common pathologies which can cause this symptom, most of which originate in the gastrointestinal tract. However, there are also extragastrointestinal conditions which can manifest as epigastric pain, several of which are cardiac. In any patient presenting with this symptom, it is vital to rule out an acute cardiac event such as a myocardial infarction or aneurysm rupture. We present the case of a ruptured sinus of Valsalva aneurysm presenting as a 4-day history of epigastric pain. Case historyA 59-year-old woman, with no previous medical history of note, presented to the accident and emergency department with a 4-day history of worsening epigastric pain and feeling generally unwell. Four days previously she had 'fainted' twice but had not sought medical attention. On admission, she was hypotensive and tachycardic. Examination findings were tenderness in the right upper quadrant and epigastrium but no peritonism, and a possibility of muffled heart sounds although the attending doctor was unsure. Her arterial blood gases showed a metabolic acidosis with a lactate level of 2.6 mmol/l. She was referred to the general surgeons at this point.After initial resuscitation, she underwent a computed tomography (CT) thorax and abdomen. CT thorax showed a 2.5 cm pericardial effusion. She was seen by a cardiologist who found distended neck veins and mixed murmurs at the apex. He performed an echocardiogram which confirmed the presence of a pericardial effusion and that it was causing right atrial and ventricular collapse, an indication for drainage. Pericardiocentesis was performed by the consultant cardiologist and she was transferred to the coronary care unit.A repeat transthoracic echocardiogram showed a 4-cm sinus of Valsalva aneurysm anteriorly with moderate aortic regurgitation. There was no flow into the pericardial space at this time. It was felt that the aneurysm had ruptured into the pericardial space but had tamponaded. She underwent a repair of this aneurysm the following day. Operative findings Northern General Hospital, Sheffield, UK ABSTRACT As general surgeons, we are regularly referred patients with epigastric pain. There are a huge number of common pathologies which cause this complaint, most of which are gastrointestinal in origin. Although the old adage goes 'common things are common', we must always keep our minds open to the possibility of the uncommon and not miss warning signs which are present in the history or examination. We present the case of a 59-year-old woman with a ruptured sinus of Valsalva aneurysm presenting to the accident and emergency department as epigastric pain. ON-LINE CASE REPORT