Pancreatic Heart Paralysis

A 46 year old Caucasian female presents to the ER for evaluation of generalized weakness and mild left lower quadrant abdominal pain. In the ER, she was noted to have a heart rate of 23. She was given atropine with improvement in heart rate to 46. Cardiology was consulted and treatment options were discussed including obtaining an electrophysiologist consult and possible pacemaker insertion for symptomatic bradycardia of unknown origin. With a concerning heart rate prone to progressive bradycardia, she was sent to the MICU for closer evaluation with pacer pads and the crash cart in close proximity. Patient reported mild left lower quadrant abdominal pain which she attributed it to the fatty meal she had the previous day. She described it as an intermittent pain on the left side of her abdomen without radiation to her back. She had taken TUMS prior to admission without relief. She denied diarrhea, hematochezia, nausea, or fever. She denied any significant cardiac history, chest pain or shortness of breath. Lab results revealed a lipase of 3,413. CT of the abdomen revealed stranding in the mesentery surrounding the uncinate process and head of the pancreas consistent with acute pancreatitis. With treatment of her underlying pancreatitis, her bradycardia resolved. This case illustrates a form of viscero-visceral reaction which could lead providers astray in making the initial diagnosis. Although this presentation of pancreatitis is rare, it is not uncommon for autonomic dysfunction to be a presenting sign of an underlying disorder in an otherwise healthy individual.