Never Ignore a GUT Feeling!

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Purpose: Takotsubo cardiomyopathy is an increasingly recognized entity. It is known to occur in the setting of extreme catecholamine release and sympathetic activity, which can be seen with highintensity vomiting and severe abdominal pain, resulting in myocardial stunning and associated transient cardiomyopathy without evidence of angiographically definable coronary artery disease. We are describing a case of Takotsubo cardiomyopathy with atypical presentation in the setting of highintensity vomiting and epigastric abdominal pain. A 60-year-old woman with past medical history of hypertension and type 2 diabetes initially presented to an outlying hospital complaining of nausea and highintensity vomiting of two weeks' duration that started after she was prescribed Exenatide for her diabetes. Her vomiting had been progressively getting worse, and was associated with epigastric abdominal pain. She was hemodynamically stable. EKG showed T wave inversion in leads V2-V6 indicative of ischemia, but her cardiac enzymes were not elevated. She was transferred to our facility for further management. Laboratory parameters including liver panel, amylase, lipase and lactate were all within normal limits. Abdominal X-ray and liver/gall bladder Doppler ultrasound were unremarkable. An echocardiogram was done on admission, which showed left ventricular ejection fraction (LVEF) of 40%, with apical segment akinesia and ballooning. Her LVEF 6 months ago was normal, at 55%. Echocardiogram findings were very suggestive of Takotsubo cardiomyopathy, so the patient was scheduled for cardiac catheterization, which showed normal coronary angiography. Left ventriculography demonstrated akinesia of the apical segment and apex with good contractility of the basal segments. A diagnosis of Takotsubo cardiomyopathy was established and the patient was scheduled for an esophagogastroduodenoscopy, which was unremarkable. The patient's nausea and vomiting improved after discontinuation of exenatide, and she was discharged home in stable condition. At six weeks' follow up, she had normal LVEF and wall motion on echocardiogram. In the clinical setting of nausea, vomiting and abdominal pain, a diagnosis of Takotsubo cardiomyopathy is very rare, but not unheard of. The extreme physiologic stress produced by high-intensity vomiting may have resulted in a surge in sympathetic activity that led to myocardial stunning. Also, high-intensity vomiting could have been a marker for increased sympathoadrenergic activity of an independent but unknown cause. In conclusion, Takotsubo cardiomyopathy can present with gastrointestinal symptoms, so clinicians and especially gastroenterologists should be aware of this relatively uncommon entity.