The Case of the Tense Belly

Rob Orman, MD and Jenny Beck-Esmay, MD

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The summary below is from an episode of ERcast: Clinical Perspectives

Abdominal compartment syndrome is a rare but lethal cause of shock and cardiac arrest, often hiding behind abdominal distension, dyspnea, and falling urine output. Subarachnoid hemorrhage can also masquerade as STEMI, with transient ST elevation and arrhythmias despite no coronary occlusion.

Abdominal Compartment Syndrome Pearls

Venous outflow obstruction: Abdominal compartment syndrome is fundamentally a pressure problem: compression of the IVC and portal venous system can collapse preload, raise CVP, and precipitate obstructive shock.
Classic clinical triad: The bedside pattern is abdominal distension, dyspnea, and decreased urine output, with altered mental status as an additional red flag when the abdomen keeps getting tighter.
High-risk clinical settings: Trauma, burns, massive ascites, major fluid shifts, recent abdominal surgery, and transplant patients all sit in the danger zone for rising intra-abdominal pressure.
Tense abdomen arrest clue: A suddenly rigid, distended abdomen after decompensation should move abdominal compartment syndrome up the list fast, especially when the rest of the infectious or cardiopulmonary workup is thin. We get into the bedside recognition cues in the episode.
Definitive pressure relief: Initial care is supportive resuscitation, but survival hinges on decompression with laparotomy when compartment physiology is driving the collapse.

Subarachnoid Hemorrhage as STEMI Mimic

Neurogenic ST elevation: Subarachnoid hemorrhage can produce convincing ST elevation through hypothalamic-autonomic catecholamine surge, even when bedside echo shows no wall-motion abnormality.
Electrical instability pattern: The ECG footprint is broader than ST elevation alone: SAH is linked to QT prolongation, deep T-wave inversion, VT, VF, torsades, atrial fibrillation, and U waves.
Troponin prognostic signal: About one in five patients with SAH has an elevated troponin, and that biomarker tracks with worse neurologic outcomes rather than proving a primary coronary occlusion.
History-exam mismatch: When the pre-arrest story includes seizure-like activity, odd neurologic symptoms, or profound bradycardia, a STEMI tracing may be the mimic and not the diagnosis. That distinction is worth hearing in the episode.
Broadened ST elevation differential: Not all ST elevation is thrombotic MI; increased intracranial pressure, pericarditis, hyperkalemia, hypothermia, LV aneurysm, PE, and blunt trauma all belong on the board.

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References:

1.) Newman RK, et al. Abdominal Compartment Syndrome. 2021 Apr 22. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 28613682.

2.) Chatterjee S. ECG Changes in Subarachnoid Haemorrhage: A Synopsis. Neth Heart J. 2011 Jan;19(1):31-4. doi: 10.1007/s12471-010-0049-1. PMID: 22020856.

3.) Van der Bilt IA, et al. Impact of cardiac complications on outcome after aneurysmal subarachnoid hemorrhage: a meta-analysis. Neurology. 2009 Feb 17;72(7):635-42. PMID: 19221297.

4.) Lin F, et al. Prognostic Value of Elevated Cardiac Troponin I After Aneurysmal Subarachnoid Hemorrhage. Front Neurol. 2021 May 31;12:677961. PMID: 34135855.

Faculty

Rob Orman, MD
Dr. Rob Orman is an emergency physician, educator, and executive coach specializing in physician performance and professional fulfillment. After more than 20 years in community emergency medicine, he now works with clinicians across specialties to address burnout, inefficiency, and career challenges. He earned his medical degree from Emory University School of Medicine and completed his residency at Denver Health Medical Center, where he served as chief resident. Dr. Orman is the founder of the Stimulus podcast and Orman Physician Coaching. He previously served as chief editor of ERcast and hosted Essentials of Emergency Medicine for nearly a decade.
Jenny Beck-Esmay, MD