Heart and git interaction

transcript

Ahmed Abudeif Abdelaal

Assistant Lecturer of Tropical Medicine & Gastroenterology

Sohag Faculty of MedicineMay, 2015

Heart and GIT Interaction

Effect of Heart on GIT

1) Heart failure

- Heart failure is a complex syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the heart to function as a pump to support a physiological circulation.

- Heart failure leads to bowel wall edema.

- Bowel wall edema may lead to early satiety (a common symptom in heart failure), nausea, diffuse abdominal discomfort, malabsorption, and a rare form of protein-losing enteropathy.

2) Ischaemic heart disease (IHD)

- IHD is most commonly caused by obstruction or stenosis of one or more of the coronary arteries by atheromatus plaque. Obstruction can result in myocardial ischaemia and infarction.

- Anginal pain is the typical presentation of IHD. However, IHD can cause symptoms other than anginal pain, including abdominal manifestations which may be:

• Mid-epigastric burning sensation, often postprandially.

• Sharp abdominal pain (atypical, but more common in women).

• Right-upper quadrant discomfort (may mimic gallbladder disease or pancreatitis).

• Nausea and/or vomiting (often associated with increased vagal tone secondary to inferior myocardial ischemia or infarction).

3) Acute coronary syndrome (ACS)

- The term acute coronary syndrome (ACS) is used to describe the continuum of myocardial ischemia (unstable angina) or infarction (with or without concomitant ST segment elevation).

- Patients with ACS typically presents with :

• Patients with unstable angina has cardiac chest pain that is new, worsening (i.e., more severe, prolonged, or frequent than previous episodes of angina), or occurring at rest, without serologic evidence of myocyte necrosis (i.e., no elevation of serum concentrations of troponin or the MB isoenzyme of creatine kinase [CK-MB]).

• The patient with cardiac chest pain with serologic evidence of myonecrosis and without ST segment elevation is said to have a non-ST segment elevation myocardial infarction (NSTEMI).

• The patient with acute-onset cardiac chest pain, serologic evidence of myonecrosis, and persistent (>20 minutes) ST segment elevation is said to have an ST segment elevation myocardial infarction (STEMI).

- Atypical presentations of ACS are common and may includeaching or vague chest discomfort, epigastric pain, acute-onset indigestion, nausea, vomiting, unexplained fatigue, or dyspnea.

- Such atypical complaints are often observed in younger (25 to 40 years of age) and older (>75 years of age) patients, women, and patients with diabetes mellitus, chronic renal insufficiency, or dementia.

4) Aortic aneurysm

- An aortic aneurysm is pathologic dilatation of the aorta.

- The large majority of abdominal and thoracic aortic aneurysms are asymptomatic and are discovered incidentally on routine physical examination or imaging study.

- When patients with abdominal aortic aneurysms experiencesymptoms, pain in the epigastrium radiating to the back is the most frequent complaint, some patients presents with a pulsatile, expansile abdominal mass.

- With rupture, the pain is frequently associated with hypotension, tachycardia, profound anaemia and sudden death.

- An enlarging aneurysm may produce local mass effects as a result of compression of adjacent mediastinal structures, with symptoms including coughing, wheezing, dyspnea, dysphagia, hoarseness or recurrent pneumonia.

- Rarely, aortic aneurysm leads to aorto-oesophageal or aorto-duodenal fistula which may cause haematemesis.

4) Aortic dissection

- Aortic dissection occurs when the media of the blood vessel is cleaved longitudinally to form a false lumen that communicates with the true lumen.

- Severe central chest pain radiating to the back, abdomen or lower extremities mimicking myocardial infarction is the most common initial symptom.

- Aortic dissection may result in vascular complications including mesenteric ischaemia or frank intestinal infarction.

5) Cardiovascular drugs

- Optimal treatment of patients with cardiovascular disease often requires the use of multiple medications, which have several GIT side effects.

A) Drugs producing upper GIT adverse effects; mechanisms:

• Direct mucosal irritation or injury: aspirin and other NSAIDs, potassium supplementation.

• Relaxation of the cardiac sphincter: Ca+2 channel blockers, nitrates.

• Alteration of gastric motility (bradykinin-mediated dysmotility): ACEIs, ARBs.

5) Cardiovascular drugs

B) Antiplatelets (aspirin, clopidogrel) and anticoagulants (warfarin, heparin) may produce GIT ulceration and bleeding.

C) Digoxin toxicity: nausea, vomiting, diarrhea, abdominal pain.

Effect of GIT on Heart

Effect of GIT on the Heart

1) Rhythm disturbance and syncope related to esophageal disease

- Disturbances in cardiac rhythm accompanying swallowing are well documented.

- Bradyarrhythmias including (AV block, sinus bradycardia and ventricular asystole) are more common. However, swallowing induced tachyarrhythmias have also been described such as AF.

- Evaluation of these patients has revealed that many of them suffer from an underlying gastrointestinal disorders including GERD, hiatus hernia, achalasia and gastric diverticulae.

2) Linked angina

- This term is used to describe a condition in which gastrointestinal factors can induce angina like chest pain and ECG changes in patients with proven coronary artery disease.

- It had previously been shown that raising the pressure in the bile ducts of patients with angina could provoke typical angina pain, and that hiatus hernia correction could lead to symptomatic relief of co-existent symptoms of IHD.

- More recently, it has been demonstrated that administering acid into the esophagus of patients with coronary artery stenosis will reduce their exercise tolerance levels.

- Therefore, it has been postulated that there is a neural reflex capable of altering cardiac blood flow or cardiac pain perception on stimulation of the esophageal mucosa.

- Ischaemic ECG changes had been described at times of esophageal spasm in variant angina patients, this postulates that esophageal spasm and coronary spasm are mutual and reciprocal.

3) Noncardiac chest pain (NCCP)

- The term noncardiac chest pain generally means pain in the chest that mimics or may be confused with cardiac chest pain.

- Many patients who present to a physician with acute chest pain have a noncardiac cause.

- Diagnosis is particularly confusing in patients who have both cardiac and noncardiac chest pain.

- GIT causes of NCCP:A) Esophageal disease.a. Motility disorders.1) Achalasia.2) Diffuse esophageal spasm.3) Nutcracker esophagus.4) Nonspecific motor disorder.

b. Mucosal disorders.1) GERD, NERD.2) Viral and fungal infections.3) Acid or alkali ingestion.4) Cancer.

B) Gall bladder disease.C) Pancreatitis.D) Peptic ulcer.

4) Malabsorption

a) Beriberi

- Refers to a cluster of symptoms caused primarily by a nutritional deficit in vitamin B1 (thiamine).

- Beriberi has conventionally been divided into three separate entities, dry, wet and infantile.

- Wet beriberi is the type that affect the heart.

4) Malabsorption

Wet Beriberi

- Wet beriberi affects the heart and circulatory system. It is sometimes fatal, as it causes a combination of heart failure and weakening of the capillary walls, which causes the peripheral tissues to become edematous.

- Wet beriberi is characterized by:

• Increased heart rate.

• Vasodilation leading to decreased systemic vascular resistance, and high output heart failure.

4) Malabsorption

Wet Beriberi

• Elevated jugular venous pressure.

• Dyspnea on exertion.

• Paroxysmal nocturnal dyspnea.

• Peripheral oedema.

4) Malabsorption

b) Pellagra

- Pellagra is a vitamin deficiency disease most frequently caused by a chronic lack of niacin (vitamin B3).

- Pellagra is classically described by "the three Ds": diarrhea, dermatitis, dementia. Symptoms includes:

• Photosensitivity, aggression, dermatitis, alopecia, oedema, glossitis, red skin lesions, insomnia, weakness, mental confusion, ataxia, paralysis of extremities, peripheral neuritis, diarrhea, dilated cardiomyopathy, dementia.

4) Malabsorption

c) Anaemic heart failure.

d) Hypokalemia, leads to prominent U wave, bradycardia, cardiac arrest.

5) Carcinoid syndrome

- Occurs in approximately 5% of carcinoid tumors.

- It is caused by endogenous secretion of mainly serotonin and kallikrein.

- Carcinoid syndrome generally does not occur until the disease is so advanced that it overwhelms the liver's ability to metabolize the released serotonin.

- It is characterized by:

• Flushing.

• Diarrhea, nausea, and vomiting.

• Bronchoconstriction.

• Secondary restrictive cardiomyopathy. Occurs in about 50% of patients, caused by serotonin induced fibrosis of the valvular endocardium, notably the tricuspid and pulmonary valves. It ends with heart failure.

6) Inflammatory bowel disease (IBD)

- Pericarditis with or without an effusion have been described in patients with active IBD.

- Cardiac arrhythmias are observed in patients with IBD more commonly ulcerative colitis than chron’s disease. There are several case reports of patients presented by collapse due to arrhythmias or complete heart block.

7) GIT drugs

1) Proton pump inhibitors competitively inhibit the cytochrome P450 2C19 isoenzyme (CYP2C19). Omeprazole and esomeprazole are the most potent CYP2C19 inhibitors. Clopidogrel is a CYP2C19 substrate and needs to be activated by this isoenzyme. When given concurrently with proton pump inhibitors, there is a reduction in the produced active form of clopidogrel and greater platelet reactivity.

7) GIT drugs

2) Cisapride is a prokinetic drug that cause QT prolongation, resulting in fatal cardiac arrhythmia.

3) IV erythromycin stimulates motilin receptors and can be used as a prokinetic agent. It cause QT prolongation and arrhythmogenic risk as well.

4) The 5HT3 antagonists (dolasetron, granisetron, ondansetron, etc) and the histamine 2 receptor antagonists (cimetidine, ranitidine) can cause bradycardia or heart block when used in excessive doses or in intravenous forms.

7) GIT drugs

5) Metoclopramide can profoundly elevate blood pressure in patients with pheochromocytoma. In addition, it has been shown to modestly attenuate the antihypertensive effects of bromocriptine and labetolol.

Diseases that affect both

heart and GIT

Diseases that affect both heart and GIT

A) Atherosclerosis, systemic vasculitis, hypercoagulable states, thromboembolism

- Effect on GIT:

- They are risk factors for mesenteric and colonic ischaemia.

- Effect on heart:

- They are risk factors for IHD and ACS.

B) Parasitic diseases

1) Trichinella spiralis

- Effect on GIT:

- This occurs during the initial intestinal phase, that occurs within days after infection. There is mild symptoms in the form of diarrhoea, abdominal pain and vomiting.

- Effect on heart:

- T. spiralis can lead to myocarditis that may result in myocardial damage, heart failure, or arrhythmias.

2) Heterophys heterophys

- Effect on GIT:

- Presence of the worm in the intestine can lead to abdominal colic, diarrhoea, bloody stool.

- Effect on heart:

- Egg emboli can lead to myocarditis, cardiomyopathy and heart failure.

3) Schistosomiasis

- Effect on GIT:

- Abdominal pain, bilharzial dysentery, prolapse of anal mucosa due to tenesmus, anal fistula and fissure.

- Effect on heart:

- Bilharzial pulmonary hypertension, cor pulmonale, pulmonary aneurysm. Bilharzial ova can cause military foci of fibrosis in the myocardium.

4) Taenia solium

- Effect on GIT:

- Presence of the worm in the intestine can lead to abdominal discomfort, nausea, anorexia.

- Effect on heart:

- Cardiac cysticercosis is a rare and typically asymptomatic infection. However, there is a few case reports about conduction defects and arrhythmias.

5) Trypanosoma cruzi (Chagas’ disease)

- Effect on GIT:

- Affection of the esophagus leads to megaesophagus with symptoms similar to those of achalasia.

- Affection of the colon leads to megacolon intermittent abdominal pain and chronic constipation.

5) Trypanosoma cruzi (Chagas’ disease)

- Effect on heart:

- During acute stage of the disease severe myocarditis may occur leading to congestive heart failure.

- During chronic stage there is arrhythmias, cardiomyopathy, heart failure.

6) Entamoeba histolytica

- Effect on GIT:

- Acute amoebic dysentery.

- Chronic amoebiasis with dyspepsia, abdominal distention, bulky offensive stool.

6) Entamoeba histolytica

- Effect on heart:

- Amoebic pericarditis.

- Emetine side effects in the form of myocarditis, pericardial pain and ECG changes.

7) Sarcocystis spp.

- Effect on GIT:

- Often asymptomatic; nausea, vomiting, abdominal pain, and diarrhea may occur, eosinophilic necrotizing enteritis has been reported.

- Effect on heart:

- Cardiac involvement is very rare, usually asymptomatic. However, conduction abnormalities have been reported.

8) Malaria

- Effect on GIT:

- Persistent vomiting, epigastric pain, diarrhoea may develop early.

- Algid malaria, characterized by watery diarrhoea (cholera like) or dysentery symptoms.

8) Malaria

- Effect on heart:

- Early in the disease, chest pain, palpitation, rarely heart failure.

- Microthrombosis of coronaries and occlusion by the parasite.

- Myocardial lesions may occur due to interstitial infiltrates and haemorrhages.

9) Visceral leishmaniasis (Kala azar)

- Effect on GIT:

- Diarrhoea or dysentery due to intestinal ulcers.

- Effect on heart:

- Myocarditis and suppurative pericarditis.

10) Balantidium coli

- Effect on GIT:

- Chronic dysentery.

- Effect on heart:

- Myocarditis, cardiac dilatation and pericardial effusion.

C) Bacterial diseases

1) Brucellosis

- Effect on GIT:

- During acute disease, there is may be abdominal pain, diarrhoea, constipation, vomiting.

- Effect on heart:

- Bacterial endocarditis affecting mainly aortic valve.

2) Abdominal TB

- Effect on GIT:

- Abdominal pain, episodes of diarrhoea and constipation, malabsorption, intestinal obstruction.

- Effect on heart:

- TB pericarditis.

3) Typhoid fever

- Effect on GIT:

- Abdominal pain, distension, diarrhoea, constipation, anorexia, nausea, vomiting, GIT bleeding, perforation.

- Effect on heart:

- Toxic myocarditis.

4) Q fever

- Effect on GIT:

- Non specific symptoms; Abdominal pain, anorexia, nausea, vomiting.

- Effect on heart:

- During acute disease, there is may be myocarditis and pericarditis.

4) Q fever

- In chronic disease, there is may be:

• Q fever endocarditis with progressive degradation of valve function and progressive heart failure.

• Vascular aneurysms.

• Chronic pericarditis

5) Whipple Disease

- The disease is caused by actinobacter Tropheryma whipplei.

- Effect on GIT:

- Intestinal malabsorption.

- Effect on heart:

- Endocarditis, pericarditis.

6) Listeriosis

- Effect on GIT:

- Self limited febrile gastroenteritis in healthy persons.

- Effect on heart:

- Endocarditis in immunosuppressed.

7) Helicobacter pylori

- Effect on GIT:

- Peptic ulcer disease.

- Adenocarcinoma and MALT lymphoma.

- Effect on heart:

- There is an association between H. pylori infection and coronary artery disease.

7) Helicobacter pylori

- The possible mechanisms include persistent local or systemic inflammation and initiating autoimmune responses (vasculitis).

8) Campylobacter jejuni

- Effect on GIT:

- Abdominal pain, watery or bloody diarrhoea, vomiting.

- Effect on heart:

- Rarely endocarditis.

D) Fungal diseases

1) Candidiasis

- Effect on GIT:

- Oropharyngeal Candidiasis, esophagitis.

- Effect on heart:

- Endocarditis, usually fatal complication of candidemia.

D) Fungal diseases

2) Aspergillosis

- Effect on GIT:

- Esophageal and intestinal ulcers, mesenteric thrombosis with GIT bleeding.

- Effect on heart:

- Endocarditis.

E) Hyperesinophilic syndrome

- Characterized by sustained eosinophilia for at least 6 months, organ dysfunction and exclusion of other aetiologies.

- Effect on GIT:

- Dysphagia, nausea, vomiting, abdominal pain, diarrhoea, malabsorption.

- Effect on heart:

- Thromboembolism, tricuspid regurge, mitral regurge, heart failure.

F) Non-Hodgkin’s lymphoma (NHL)

- NHL can involve any organ in the body.

- Effect on GIT:

- Depends on its location:

• Esophageal lymphoma: dysphagia, odynophagia.

• Gastric lymphoma: dyspepsia, nausea, vomiting, rarely mass.

• Small intestinal lymphoma: malabsorption, diarrhoea.

• Colorectal lymphoma: abdominal pain, bleeding per rectum, mass.

F) Non-Hodgkin’s lymphoma (NHL)

- Effect on heart:

- Cardiac lymphoma is very rare.

- May be presented by; arrhythmias, valve incompetence, heart failure, pericardial effusion.

G) Leukaemia

- Leukaemia can infiltrate any organ.

- Effect on GIT:

- Depends on its location.

- Effect on heart:

- Arrhythmia, cardiomyopathy, heart failure, pericarditis.

H) Inherited syndromes

1) Down’s syndrome (Triosomy 21)

- It is a genetic disorder caused by the presence of all or part of a third copy of chromosome 21.

- Effect on GIT:

- Constipation occurs in nearly 50% (2-15% due to Hirschsprung's disease).

- Other frequent congenital problems include duodenal atresia, pyloric stenosis, Meckel diverticulum, and imperforate anus.

1) Down syndrome (Triosomy 21)

- Celiac disease affects about 7–20% and GERD is also more common.

- Effect on heart:

- The rate of congenital heart disease is around 40%.

- ASD, VSD, mitral valve problems, tetralogy of Fallot and PDA.

2) Edward’s syndrome (Triosomy 18)

- It is a chromosomal abnormality caused by the presence of all, or part of, an extra 18th chromosome.

- Effect on GIT:

- Omphalocele, esophageal atresia.

- Effect on heart:

- ASD, VSD, PDA.

3) Heyde's syndrome

- It is a syndrome of aortic valve stenosis associated with gastrointestinal bleeding from colonic angiodysplasia.

4) Noonan syndrome

- It is a relatively common autosomal dominant congenital disorder that affects both males and females. It is referred to as the male version of Turner's syndrome.

- Effect on GIT:

- Dysphagia, anorexia, vomiting, intestinal malrotation, gastroparesis.

4) Noonan syndrome

- Effect on heart:

- ASD, VSD, pulmonary stenosis, hypertrophic cardiomyopathy.

Thank you

Heart and git interaction

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