Palpation of the abdomen. A routine procedure or a diagnostic tool?

A 57-year-old woman came to our attention for the evaluation of recurrent episodes of syncope associated with tachycardia and prolonged hypotension. She did not have a history of hypertension. Three years previously (July 2002), while coming out from the swimming pool, she felt deep malaise, nausea, palpitations, light headedness, no chest pain. She describes the first episodes as a near-syncope without lose of consciousness, and all symptoms disappeared within approximately 15 min in the supine position. During summer she had other three episodes with similar characteristics so that a large series of clinical and instrumental investigations were performed. In October 2002, while wearing a dynamic electrocardiographic recorder (Holter), the patient had a new episode of malaise and vomiting. Symptoms appeared suddenly while the patient was blinking the carpets from the railing of the balcony. The recording revealed two runs of polymorphic sustained ventricular tachycardia of approximately 30 beats, with wide QRS, at a frequency of 180/min, simultaneous with the reported symptoms. The base rhythm was sinusal, with frequent ventricular ectopy, and short periods of second degree atrioventricular block type Wenckebach without meaningful pauses. Diagnosis of bidirectional ventricular tachycardia was made. An electrophysiological study (November 2002) excluded triggered ventricular and supraventricular tachyarrhythmia and showed normal sinus function and atrioventricular conduction. Likewise, coronary vessels were found to be normal at angiography. Medical therapy with beta-blockers was advised. Notwithstanding the treatment, near-syncope episodes occurred again during the following 2 years with increasing frequency. In June 2004, an effort myocardial scintigraphy with thallium-201 excluded reduced coronary reserve. During all this period she was