Hemodynamic Compromise Due to Semaglutide-Associated Abdominal Distension

Glucagon-like peptide-1 (GLP-1) agonists are becoming widely used, but commonly cause gastrointestinal side effects that are often mild but can occasionally be significant. A 35-year-old male patient with obesity and otherwise minimal medical history presented to the emergency department after a syncopal episode that occurred several days after restarting high-dose GLP-1 agonist therapy. Imaging showed massive gastric distension with significant inferior vena cava compression. He developed low-output shock requiring very high-dose vasoactive medications, which resolved after gastric decompression via emesis, nasogastric tube placement, and intravenous fluid resuscitation. This case represents a heretofore unseen side effect of glucagon-like peptide-1 receptor agonist administration, with initiation of maximum-dose semaglutide leading to dramatic gastric distension causing inferior vena cava compression and low-output shock. In patients with unexplained hypotension, shock, and/or syncope on glucagon-like peptide-1 agonist therapy, adverse medication effects should be considered as possible etiologies. This case emphasizes the importance of gradual dose escalation of glucagon-like peptide-1 agonists under provider guidance.