Refractory Bradycardia in the Late Phase of Necrotizing Pancreatitis: A Case Report.

ECG abnormalities are common in acute pancreatitis, yet clinically significant bradyarrhythmias are rarely reported and have been described mainly in the early phase of the disease. We report the case of a 76-year-old hypertensive male who developed severe acute post-endoscopic retrograde cholangiopancreatography pancreatitis, complicated by infected pancreatic necrosis requiring readmission to the intensive care unit on day 20. He was managed with CT-guided drainage and culture-directed antibiotics. In the fourth week of illness, he developed recurrent sinus bradycardia, at times triggered by vagal stimuli (nasogastric tube placement and posture change) and at times occurring spontaneously. On days 25 and 28, he developed severe bradycardia refractory to IV atropine, progressing to cardiac arrest on both occasions; each was managed with brief CPR and a 1 mg IV bolus of epinephrine, with return of spontaneous circulation. On day 30, a further arrest occurred and could not be reversed despite prolonged CPR. Throughout these episodes, serial ECGs showed sinus bradycardia without conduction block, cardiac enzymes and echocardiographic parameters remained unremarkable, electrolytes were within normal range, and inflammatory biomarkers were declining; these findings did not support an alternative reversible cause. We discuss the potential pathophysiological mechanisms underlying this presentation and suggest that life-threatening bradyarrhythmias may also arise in the late phase of necrotizing pancreatitis, raising the case for a low threshold for proactive, aggressive management of bradyarrhythmia in this setting.