ELECTROCARDIOGRAPHIC CHANGES IN GASTROINTESTINAL DISEASE: FOCUS ON HIATAL HERNIA

Abstract

Introduction. Chest pain accompanied by electrocardiographic changes is primarily evaluated as a possible acute coronary syndrome, but certain digestive pathologies can mimic myocardial ischemia, especially large hiatal hernia, gastric dilatation, and intestinal obstruction.

Aim of the study. Synthesis of recent data from the literature regarding electrocardiographic changes encountered in hiatal hernia and other gastrointestinal pathologies, highlighting useful elements in the differential diagnosis with cardiovascular pathology.

Materials and methods. A narrative synthesis of the literature was conducted by analyzing articles identified in PubMed and Google Scholar, supplemented with contemporary guidelines and relevant international publications, published mainly between 2015–2025, regarding the evaluation of chest pain accompanied by electrocardiographic changes within the cardio-digestive interrelationship.

Results. The reviewed literature shows that some digestive disorders can mimic myocardial ischemia and can be associated with ST segment elevations, but also with repolarization abnormalities such as ST segment depression, deeply negative or biphasic T waves in the precordial leads and, less frequently, apparently pathological Q waves. Large hiatal hernia is most frequently associated with pseudo-ischemic changes, through mediastinal compression, displacement of the heart and viscero-cardiac reflexes. Other entities relevant for the differential diagnosis are gastric dilatation, intestinal obstruction, gastroesophageal reflux disease and esophagitis. In the evaluation, the electrocardiogram and serial cardiac troponin testing remain essential, and echocardiography and thoraco-abdominal computer tomography (CT) can demonstrate extrinsic cardiac compression from the hiatal hernia. When gastric neoplasia is suspected, CT and endoscopic ultrasonography contribute to the characterization of the lesion and staging. Coronary calcium score in selected patients and diagnostic coronary angiography complete the algorithm.

Conclusions. Gastrointestinal pathology should be considered in the differential diagnosis of chest pain accompanied by electrocardiographic repolarization changes, especially when the clinical picture, biomarkers, and imaging studies do not convincingly argue for a coronary etiology.