Heart block and nonocclusive mesenteric ischemia
© Springer-Verlag London Ltd 2009
Received: 13 January 2009
Accepted: 22 February 2009
Published: 29 April 2009
Upon further evaluation, she was found to have heart block with non-occlusive mesenteric ischemia. The ECG reveals second-degree atrioventricular block with 2:1 conduction. If the PR interval increases progressively prior to a non-conducted P wave, the atrioventricular block is Mobitz type I. In Mobitz type II, the non-conducted beats are not heralded by an increasing PR interval, as noted in this patient . All type II or symptomatic type 1 patients are candidates for pacemaker implantation .
The CT image reveals colonic wall thickening with mesenteric stranding, consistent with ischemic colitis. However, the mesenteric vessels were patent, leading to a diagnosis of nonocclusive mesenteric ischemia. Up to 30% of mesenteric ischemia cases fall into this category, usually in the setting of low cardiac output . Previous case reports most often describe this phenomenon in settings such as hemodialysis and cardiac or vascular surgery [4-6]. As with all mesenteric ischemia, the classic presentation is pain out of proportion to the exam; hematochezia and lactic acidosis are late findings whose absence should not influence the workup. We believe our patient’s heart block and bradycardia impaired cardiac output, causing bowel hypoperfusion. The normal blood pressure we observed must have belied prior periods of hypotension.
Treatment is directed at reversal of the low-flow state, sometimes followed by injection of vasodilators such as papaverine into the mesenteric vessels . Our patient had a pacemaker placed and subsequently recovered uneventfully.
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