A 52-year-old female with no significant past medical history presented to our ED for evaluation of syncope. The episode occurred at work while she was sitting down. There was a prodrome of spots in her vision and lightheadedness. She had loss of consciousness for a few seconds, and there was no reported seizure-like activity or post-ictal state. She reported that she had been feeling well before and after the event. She denied a history of previous syncope, chest pain, shortness of breath, abdominal pain, vomiting, diarrhea, blood in the stool, and vaginal bleeding. There was no family history of cardiac disorders.

 

Initial VS: HR 90, BP 119/79, RR 20, SpO2 98% on RA, T 36.5 °C

 

An ECG, seen below, was obtained that showed normal sinus rhythm with normal intervals and no ectopy.

 

A bedside cardiac ultrasound was performed as part of the work-up as is often done in our ED when a patient presents with syncope.

 

Here is the para-sternal long view:

 

Here is the para-sternal short view:

 

Here is the apical 4-chamber view:

 

All of the above images were interpreted as within normal limits. Then a subcostal 4-chamber view was obtained:

 

The heart still appeared normal, but something caught the eye of the sonographer:

 

This was investigated more:

 

There is a homogenous mass seen adjacent to the liver, compressing the IVC.

 

Could the cause of her syncope be obstruction of venous return to the heart?

 

The providers were unsure. A CT scan of the abdomen was obtained to better define the mass. Here are some of the images:

 

The mass was thought to be either a large pancreatic pseudocyst, a low-grade cystic pancreatic neoplasm, or a duodenal duplication cyst.

 

The patient was admitted for further work-up given that she stated that she would not follow-up as an outpatient. She unfortunately eloped from the hospital shortly after admission. She presented to ED in cardiac arrest about 1 month later and was unable to be resuscitated. The cause of the arrest was unknown.

No autopsy was performed.

What do you think it is?