The Heart Under Pressure: Transient ST-Segment Elevation Due to Severe Intestinal Distension

Acute extracardiac conditions can occasionally produce electrocardiographic abnormalities that closely mimic acute coronary occlusion, posing a diagnostic challenge and increasing the risk of unnecessary activation of invasive cardiac pathways. Severe gastrointestinal distension, although uncommon, is a recognized cause of transient ST-segment elevation due to mechanical displacement of the heart, autonomic imbalance, and abrupt changes in ventricular loading conditions. These alterations may be particularly misleading in patients with chronic regional wall motion abnormalities, in whom new ECG changes risk being misinterpreted as recurrent ischemia. We report the case of a 68-year-old man with a history of inferior myocardial infarction who presented with marked abdominal distension secondary to a closed-loop small bowel obstruction. Despite the absence of chest pain, his ECG showed significant anterolateral ST-segment elevation. High-sensitivity troponin I remained negative, and transthoracic echocardiography demonstrated preserved anterior and apical motion, chronic inferior akinesia, and unchanged global longitudinal strain. Following nasogastric decompression, the ST-segment normalized completely within fifteen minutes. Subsequent imaging confirmed a closed-loop volvulus requiring urgent surgical intervention, with full bowel viability preserved. This case underscores the importance of integrating clinical context, biomarkers, and rapid echocardiographic assessment when evaluating ST-segment elevation, helping avoid unnecessary coronary angiography in the presence of extracardiac causes.