Abstract Introduction Caustic ingestion affects 5,000-15,000 Americans annually, with alkaline agents like sodium hydroxide causing severe injury through liquefaction necrosis and transmural damage.1 While ST-segment elevation typically suggests acute coronary syndrome, non-cardiac conditions including severe gastrointestinal pathology can produce similar findings. Case Presentation A 22-year-old male with a past medical history significant for bipolar disorder type 1 and generalized anxiety disorder presented to emergency department (ED) after an intentional ingestion of unknown amount of drain cleaner. He was intubated for airway protection after multiple episodes of hematemesis transferred to intensive care unit (ICU). Computed tomography demonstrated severe edema involving the esophagus and stomach raising concern for transmural injury. In the ICU, acute ST-segment elevation was noted on telemetry, prompting an electrocardiogram that confirmed ST-segment elevation (Figure). Initial troponin I was markedly elevated at 85.15 ng/mL. Despite these findings, the patient remained hemodynamically stable without shock. Transthoracic echocardiography demonstrated normal left ventricular systolic function, with no evidence of pericardial effusion or wall motion abnormalities. Based on normal cardiac function and the clinical context, our working diagnosis was ST-segment changes secondary to esophagitis. Endoscopy showed Zargar grade 3A caustic esophagitis at the cricopharyngeus, grade 2A in the upper third, and grade 3B with multiple ulcerations and necrosis (brown-black or greyish discoloration) in the middle and lower thirds of the distal esophagus (Figure). Despite these severe findings, the patient remained hemodynamically stable with no clinical evidence of perforation. Serial electrocardiograms obtained throughout hospitalization showed progressive improvement, with the study obtained on day 7 demonstrating near-complete resolution of the previously noted ST-segment abnormalities. The patient had a prolonged hospital stay complicated by acute respiratory distress syndrome and unfortunately died after experiencing massive airway hemorrhage. Discussion This case demonstrates how progressive caustic esophagitis can produce dramatic reversible ST-segment elevation without primary cardiac disease, illustrating a critical phenomenon gastroenterologists must recognize when managing caustic ingestions. The intimate anatomical relationship between the esophagus and cardiac structures could explain this presentation, as the esophagus courses immediately posterior to the left atrium and along the inferior surface of the left ventricle, separated only by thin tissue planes. The complete reversibility of electrocardiographic changes with conservative management indicates these represent inflammatory rather than ischemic phenomena, supporting a non-invasive approach when the clinical context is clear. Early recognition should prompt electrocardiographic evaluation and echocardiography to exclude primary cardiac pathology while maintaining focus on aggressive management of the underlying esophageal injury. This abstract is funded by: none
Ansari et al. (Fri,) studied this question.