Lab/X-ray/ECG Rounds

James HuffmanJanuary 15, 2009

67y.o. Female

Epigastric aching/burning for ~ 4 hours

Radiates to LUQ/Left chest, ?back

Associate N/V, diaphoresis

Onset while walking to car after bingo (she won $50)

History of HTN, ++smoking, EtOH abuse

Case: Continued

36.9°C, 106/63, 62, 20, 96% 3L

Chemstrip: 7.3

CVS: unremarkable

Resp: fine crackles throughout bases

Abdo: Tenderness in the epigastrum (non-peritoneal)

Cath Lab

Normal coronary arteries

No wall motion abnormalities

Now what?

Vitals unchanged

Pain moderately better post morphine

Labs:Lipase: 2445 U/LMinor elevations in other LFT’sTnT <0.03 ng/mL

ECG Manifestations of Gastrointestinal

Disease

Objectives

Review the electrocardiographic manifestations of gastrointestinal disease:

ST ElevationT-wave inversionBradycardiaQT prolongation

Understand the basic pathophysiology and significance of these changes

ContextChan, T.C. et al. ECG in Emergency Medicine and Acute Care. CH68

ECG is often obtained in initial w/u of abdo pain:Anginal variant (especially women, diabetics)

BUTSeveral GI processes are assoc. with ecg changes:

Pancreatitis, Cholecystitis, PUD, Appendicitis, IBD, Cirrhosis, electrolyte abnormalities

Certain GI processes seem to be assoc. with increased risk for concurrent cardiac ischemia or infarction

ST Elevation

STE in the setting of abdominal pain should always raise concern for ACS

Two scenarios:1. Certain GI diseases may present with ECG

consistent with pseudoinfarction e.g. acute pancreatitis, cholecystic disease

2. Certain GI diseases and treatments increase the propensity for coronary thrombosis and true ACS

e.g. IBD

ST Elevation – PseudoinfarctionRubio-Tapia A, et al. Electrocardiographic abnormalities in patients with acute pancreatitis. J Clin Gastroenterol. 2005;39:815-818.

Pancreatitis

Many case reports/series of anatomic STE with no evidence of CAD on angio/autopsyAbnormal ECG is common (~50%)“pseudoinfarction” pattern (~1-3%)Usually inferior, but anterior patterns also reported

Theories:Vagal stimulationProteolytic enzymes damaging myocytesEnzymatic mediated changes in platelet adhesionElectrolyte abnormalitiesCoronary vasospasm

ST ElevationChan, T.C. et al. ECG in Emergency Medicine and Acute Care. CH68.Ryan, E.T. et al. Myocardial infarction mimicked by acute cholecystitis. Ann Int Med 1992; 116:218.

Acute CholecystitisMay present with anterior ischemic patterns on their ECGs that often resolve after GB removal

The cardio-biliary reflex commonly cited as cause:GB distension may lead to vagal response producing intermittent coronary vasospasm

Others:Splenic ruptureDemand ischemia 2° to catecholamine release

ST Elevation – True diseaseEfremidis, M. et al. Acute myocardial infarction in a young patient during an exacerbation of ulcerative colitis. Int J Cardiol 1999; 70:211.

Inflammatory Bowel DiseaseAcute vascular thrombosis is a known complication of both UC and Crohn’s disease

Myopericarditis:Rare but reported complication of both IBD and an adverse drug reaction to mesalamine (5-ASA agent)

T-Wave InversionChan, T.C. et al. ECG in Emergency Medicine and Acute Care. CH68.

Duodenal perforation

Acute pancreatitis

Cholecystitis

ALL occur infrequently

BradycardiaChan, T.C. et al. ECG in Emergency Medicine and Acute Care. CH68.

1. As a result of vagal response to primary GI disorder or pain

2. Specific diseases are associated with bradycardia

Ulcerative Colitis Several cases of 2nd Degree and complete AV

block Jaundice/Bile-acid accumulation

Historically listed in causes of bradycardia Has not borne out in literature/animal studies

QT ProlongationChan, T.C. et al. ECG in Emergency Medicine and Acute Care. CH68.

CirrhosisHistorically thought only to occur in pts with EtOH cirrhosis

Now reported in almost every cirrhotic etiologyGrowing body of evidence that QT-prolongation is associated with a poorer clinical outcome

One case series has shown a significant reduction in QT interval post transplant

Malnutrition/electrolyte disorders

Celiac diseaseOne study found 1/3 of all adult pts had QT prolongation

PEARLS

ST/T wave changes associated with GI disease may represent true ACS or a pseudoischemic pattern

Pts with IBD are at increased risk for thrombotic events, including MI

Biliary-cardiac reflex is a known phenomenon which may explain the ST seen in acute cholecystitis

Cirrhosis and celiac disease can be a cause of QT prolongation