Acute on Chronic Right Heart Failure masquerading as abdominal pathology

Authors: Himanshu Gul Mirani, Nandini Menon, Arpith Sameul

Institution: Midland Metropolitan University Hospital

A woman presented with upper abdominal pain, distension, bradycardia, and HAGMA (base excess of minus 13); SBP was 170 mmHg. Initial concerns were mesenteric ischemia. Focused POCUS showed a stout IVC warranting judicious fluids. Hyperkalemia was treated. CT ruled out ischemia but noted moderate ascites, and cardiomegaly. Repeat POCUS revealed poor TAPSE, pleural effusion, biatrial dilation, TR, hepatic congestion & dependent edema. Prior records showed severe TR and RCA infarct with preserved LV function pointing to acute-on-chronic right heart failure. Bradyarrhythmia raised concerns for CHB. Lewis leads confirmed slow AF. AKI was likely due to venous congestion. Euglycemic ketoacidosis was ruled out (patient was on SGLT2 inhibitor).

Learning Points:– IVC is unreliable for fluid assessment – HAGMA causes: ketosis, ingestion, DKA, lactic acidosis, uremia– BRASH: treat the trigger– Venous congestion can cause AKI: consider offloading– Lewis leads help differentiate CHB from slow AF.