An 80-year-old patient came to an emergency for repeated syncopes (three times last week, she had not searched for medical help before). Significant bradycardia of 28 bpm was revealed. ECG showed junctional rhythm in the terrain of sinus arrest. Lab tests revealed slight elevation of leucocytes (12 900 with 59% of neutrophils), CRP 52 mg/l, creatinine 3.43 mg/dl (303 umol/l), urea 231 mg/dl (38.5 mmol/l), physiological levels of ions as well as of transaminases, GMT 98 IU/l, physiological levels of lipase and bilirubin.

Implantation of a pacemaker was performed on the day of admission. The patient was placed at a monitored bed after the implantation.

The patient complained of spastic epigastric pain and nausea 3 hours after the implantation. Symptomatic therapy was started. Neither pain nor nausea withdrew on the next day. Coronarography was performed due to suspicion of myocardial ischemia. No corresponding pathology was revealed. The patient presented with chills and shivering during coronarography. The patient was transferred to ICU for a suspicion of abdominal infection to monitor the patient´s condition and perform further examination.

The patient complained of minimal spastic pain in epigastrium during admission to ICU. Neither dyspnea nor nausea was present. Haemodynamics and breathing were stable. ECG revealed ventricular paced rhythm with visible atrial activity around 65 bpm. Body temperature 36.7 °C. The abdomen was soft, with no resistance and signs of peritoneal irritation. Auscultation revealed peristalsis. Lab tests (samples had been taken in the morning) showed a decreasing level of CRP (48 mg/l), increased level of leucocytes (16 600 with 93% of neutrophils), procalcitonin 0.17 ng/l. Levels of transaminases and bilirubin did not change. Lipase increased to 81 U/l. Levels of creatinine and urea decreased.

Quick echocardiography was performed – no RWMA was revealed, mediodorsally to right ventricle there was a small separation of pericardial space by pericardial effusion without any sign of tamponade.


Abdominal ultrasonography was performed to reveal aetiology of pain:

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